Healthcare Provider Details

I. General information

NPI: 1831816909
Provider Name (Legal Business Name): ABBY PETERSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 10TH ST SE STE 201
LE MARS IA
51031-2557
US

IV. Provider business mailing address

745 GLEN DR
MOVILLE IA
51039-7516
US

V. Phone/Fax

Practice location:
  • Phone: 712-546-4624
  • Fax: 712-546-9395
Mailing address:
  • Phone: 712-870-1745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number169768
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: