Healthcare Provider Details

I. General information

NPI: 1225981806
Provider Name (Legal Business Name): NICOLE MARIE PETTERSEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 HARMON DR
NORTHFIELD VT
05663-1035
US

IV. Provider business mailing address

292 CRAB APPLE RDG
RANDOLPH VT
05060-9524
US

V. Phone/Fax

Practice location:
  • Phone: 802-485-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025096434
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: