Provider Demographics
NPI:1992775506
Name:PETERSON, JEANNIE MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:KS
Mailing Address - Zip Code:66743-2000
Mailing Address - Country:US
Mailing Address - Phone:417-347-1078
Mailing Address - Fax:417-347-1079
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55028367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100787980AMedicaid
MO915240105Medicaid
KS100389550DMedicaid
430061375OtherRR MEDICARE
OK100787980AMedicaid