Healthcare Provider Details

I. General information

NPI: 1669481032
Provider Name (Legal Business Name): MICHELLE R PETERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 FAIR ST
MINERAL POINT WI
53565-1409
US

IV. Provider business mailing address

856 FAIR ST
MINERAL POINT WI
53565-1409
US

V. Phone/Fax

Practice location:
  • Phone: 608-987-5985
  • Fax:
Mailing address:
  • Phone: 608-987-5985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number2581-033
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2581-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: