Provider Demographics
NPI:1528747896
Name:PETERSON, TINA RENAE (APRN-BC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RENAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-0011
Mailing Address - Country:US
Mailing Address - Phone:580-399-1452
Mailing Address - Fax:
Practice Address - Street 1:1000 ROLLING HILLS LN
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-9415
Practice Address - Country:US
Practice Address - Phone:580-436-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK214202363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty