Healthcare Provider Details

I. General information

NPI: 1225497894
Provider Name (Legal Business Name): DAVID PETERSEN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 QUENTIN RD
BROOKLYN NY
11234-4244
US

IV. Provider business mailing address

2319 PINE RUN RD
LINDEN PA
17744-8149
US

V. Phone/Fax

Practice location:
  • Phone: 888-515-3834
  • Fax:
Mailing address:
  • Phone: 570-215-9965
  • Fax: 570-215-9965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSPO30250
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF406902-01
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSPO15897
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: