Provider Demographics
NPI:1295097954
Name:PETERS, TERA LYNNE (CRNA)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:LYNNE
Last Name:PETERS
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 1:121 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9417
Mailing Address - Country:US
Mailing Address - Phone:304-549-2936
Mailing Address - Fax:
Practice Address - Street 1:2830 STUART DAVIS ROAD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-542-3927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV70535367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered