Healthcare Provider Details

I. General information

NPI: 1932343001
Provider Name (Legal Business Name): NICOLE ELIZABETH PETERSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1646 305TH ST
TAMA IA
52339-9698
US

IV. Provider business mailing address

1646 305TH ST
TAMA IA
52339-9698
US

V. Phone/Fax

Practice location:
  • Phone: 641-484-4094
  • Fax:
Mailing address:
  • Phone: 641-484-4094
  • Fax: 641-484-2432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberJ-115527
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: