Healthcare Provider Details

I. General information

NPI: 1528611191
Provider Name (Legal Business Name): KATHRYN PETERSEN-THOMPSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN PETERSEN DO

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 N WASHINGTON AVE
LANSING MI
48906-4842
US

IV. Provider business mailing address

1129 N WASHINGTON AVE
LANSING MI
48906-4842
US

V. Phone/Fax

Practice location:
  • Phone: 435-592-9631
  • Fax:
Mailing address:
  • Phone: 517-939-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101027118
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: