Healthcare Provider Details

I. General information

NPI: 1134694250
Provider Name (Legal Business Name): PATRICIA PETERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7836 W JEFFERSON BLVD STE 101
FORT WAYNE IN
46804-4178
US

IV. Provider business mailing address

7836 W JEFFERSON BLVD STE 101
FORT WAYNE IN
46804-4178
US

V. Phone/Fax

Practice location:
  • Phone: 290-494-3484
  • Fax: 290-969-0188
Mailing address:
  • Phone: 260-494-3484
  • Fax: 260-959-0388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71008435A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: