Healthcare Provider Details

I. General information

NPI: 1669392726
Provider Name (Legal Business Name): TINA D PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 JUNIPER ST
SUN PRAIRIE WI
53590-1133
US

IV. Provider business mailing address

920 JUNIPER ST
SUN PRAIRIE WI
53590-1133
US

V. Phone/Fax

Practice location:
  • Phone: 608-405-0477
  • Fax:
Mailing address:
  • Phone: 608-405-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number246111
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: