1609239938 NPI number — MRS. CASEY CRUMP PETERSON NP-C

Table of content: MRS. CASEY CRUMP PETERSON NP-C (NPI 1609239938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609239938 NPI number — MRS. CASEY CRUMP PETERSON NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
CASEY
Provider Middle Name:
CRUMP
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609239938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PROSPERO HEALTH PARTNERS PC
Provider Second Line Business Mailing Address:
PROMENADE II 1230 PEACHTREE ST. NE 19TH FLOOR
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-3574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-949-0108
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 S MAIN ST STE 1300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38103-5513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-949-0108
Provider Business Practice Location Address Fax Number:
866-620-4792
Provider Enumeration Date:
04/04/2016

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: 363LF0000X , with the licence number:  RN214257 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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