Healthcare Provider Details

I. General information

NPI: 1669242004
Provider Name (Legal Business Name): JULIE PETERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20203 LYNN LN
COUNCIL BLUFFS IA
51503-2512
US

IV. Provider business mailing address

20203 LYNN LN
COUNCIL BLUFFS IA
51503-2512
US

V. Phone/Fax

Practice location:
  • Phone: 712-310-4727
  • Fax:
Mailing address:
  • Phone: 712-310-4727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: