Healthcare Provider Details

I. General information

NPI: 1740453141
Provider Name (Legal Business Name): KATIE L PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

IV. Provider business mailing address

835 S VAN BUREN ST
GREEN BAY WI
54301-3526
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number13465-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR53714
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number490
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: