Healthcare Provider Details

I. General information

NPI: 1740700368
Provider Name (Legal Business Name): LENA CAROLINE PETERSEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2017
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E CENTERTON BLVD
CENTERTON AR
72719-1225
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-795-1301
  • Fax: 479-795-1304
Mailing address:
  • Phone: 314-543-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number716670-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number342629
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number230416
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: