Basic Information
| Provider Information | |||||||||
| NPI: | 1730795030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MAREE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 GAGE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993529532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5096272983 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 KEENE RD | ||||||||
| Address2: | |||||||||
| City: | WEST RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993534901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423130 | ||||||||
| FaxNumber: | 5096288335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2020 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP61094911 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.