MEDICARE: ANNE MARIE PETERSEN NP

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	363L00000X	Nurse Practitioner	209.006139	IL
2	363L00000X	Nurse Practitioner	APRN.CNP.16586	OH

General Provider Information

NPI Number	:	1942350707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNE MARIE PETERSEN NP

Provider Business Mailing Address
First Line	:	6860 PRAIRIE VIEW DR
Second Line	:
City	:	MAINEVILLE
State	:	OH
Zip	:	45039-7251
Country	:	US
Telephone Number	:	708-890-8907
Fax Number	:

Provider Business Practice Location Address
First Line	:	6860 PRAIRIE VIEW DR
Second Line	:
City	:	MAINEVILLE
State	:	OH
Zip	:	45039
Country	:	US
Telephone Number	:	708-890-8907
Fax Number	:

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	05/19/2018

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