Healthcare Provider Details

I. General information

NPI: 1669083382
Provider Name (Legal Business Name): ANDREA NICOLE PETERSEN DNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 S LIMIT AVE
SEDALIA MO
65301-6910
US

IV. Provider business mailing address

807 LA GRAND DR
SEDALIA MO
65301-7965
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-1170
  • Fax: 573-530-1037
Mailing address:
  • Phone: 660-596-1605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020026948
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: