Healthcare Provider Details

I. General information

NPI: 1356077879
Provider Name (Legal Business Name): KATHRYN ANNE PETERSEN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 HUGHES RD STE 2500
MADISON AL
35758-3026
US

IV. Provider business mailing address

44 HUGHES RD STE 2500
MADISON AL
35758-3026
US

V. Phone/Fax

Practice location:
  • Phone: 256-464-2920
  • Fax: 256-542-3200
Mailing address:
  • Phone: 256-464-2920
  • Fax: 256-542-3200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-147633
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: