=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871481705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE KAY PETERSEN
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2025
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 813 CHESTNUT AVE
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-719-2625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 813 CHESTNUT AVE
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-719-2625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------