1023309804 NPI number — CAROL JEAN PETERSON APNP

Table of content: CAROL JEAN PETERSON APNP (NPI 1023309804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023309804 NPI number — CAROL JEAN PETERSON APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
CAROL
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEVINE
Provider Other First Name:
CAROL
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023309804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 S WEBSTER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54301-3505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-445-7222
Provider Business Mailing Address Fax Number:
920-445-7238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
744 S WEBSTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54301-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-445-7222
Provider Business Practice Location Address Fax Number:
920-445-7238
Provider Enumeration Date:
04/27/2011

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: 363L00000X , with the licence number:  4378-033 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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