Healthcare Provider Details

I. General information

NPI: 1144156605
Provider Name (Legal Business Name): FELICIA NICHOLE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35745 COUNTY ROAD 358
PAW PAW MI
49079-9236
US

IV. Provider business mailing address

35745 COUNTY ROAD 358
PAW PAW MI
49079-9236
US

V. Phone/Fax

Practice location:
  • Phone: 269-568-5434
  • Fax:
Mailing address:
  • Phone: 269-568-5434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-319477
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: