Provider Demographics
NPI:1871644583
Name:PETERS, NICKI JO (NP-C)
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:JO
Last Name:PETERS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4378 S DA VINCI WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-884-0110
Mailing Address - Fax:208-884-4508
Practice Address - Street 1:4378 S DA VINCI WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-884-0110
Practice Address - Fax:208-884-4508
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-783A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily