Healthcare Provider Details

I. General information

NPI: 1255371530
Provider Name (Legal Business Name): PAMELA TERESA PETERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W WASHINGTON AVE SUITE 300
JACKSON MI
49201-2180
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 517-841-1305
  • Fax: 517-841-1306
Mailing address:
  • Phone: 800-999-5829
  • Fax: 248-641-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704194081
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704194081
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: