Provider Demographics
NPI:1003698507
Name:PETERSON, MADELIENE ALEXANDRA
Entity Type:Individual
Prefix:
First Name:MADELIENE
Middle Name:ALEXANDRA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELIENE
Other - Middle Name:ALEXANDRA
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2221 LAKESIDE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4416
Mailing Address - Country:US
Mailing Address - Phone:469-505-1652
Mailing Address - Fax:469-436-3976
Practice Address - Street 1:170 N 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2961
Practice Address - Country:US
Practice Address - Phone:801-855-3267
Practice Address - Fax:801-855-3251
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12058297-3102163W00000X
UT12058297-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse