Healthcare Provider Details

I. General information

NPI: 1114337698
Provider Name (Legal Business Name): MORGAN MICHELLE PETERSEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W CARROLL CT
ROSEBURG OR
97471-2368
US

IV. Provider business mailing address

427 W CARROLL CT
ROSEBURG OR
97471-2368
US

V. Phone/Fax

Practice location:
  • Phone: 541-580-7378
  • Fax:
Mailing address:
  • Phone: 541-580-7378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201402485NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: