1356647143 NPI number — MRS. PENNY JO NICHOLS-PETERSON LISW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356647143 NPI number — MRS. PENNY JO NICHOLS-PETERSON LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS-PETERSON
Provider First Name:
PENNY
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
PENNY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356647143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4517 49TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50310-2969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-802-7348
Provider Business Mailing Address Fax Number:
515-255-3944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6955 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDSOR HEIGHTS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50324-1540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-802-7348
Provider Business Practice Location Address Fax Number:
515-255-3944
Provider Enumeration Date:
01/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  007260 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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