MEDICARE: DR. NANNETTE MARIE PETERSEN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS7768	FL

General Provider Information

NPI Number	:	1336152586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NANNETTE MARIE PETERSEN D.O.

Provider Business Mailing Address
First Line	:	27 RABON VALLEY ACRES RD
Second Line	:
City	:	FOUNTAIN INN
State	:	SC
Zip	:	29644-8605
Country	:	US
Telephone Number	:	864-582-7025
Fax Number	:	864-583-5715

Provider Business Practice Location Address
First Line	:	279 N GROVE MEDICAL PARK DR
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-4222
Country	:	US
Telephone Number	:	864-582-7025
Fax Number	:	864-583-5715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	03/24/2017

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