Provider Demographics
NPI:1003877911
Name:PETERSON, KAREN E (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VALLEY VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1374
Mailing Address - Country:US
Mailing Address - Phone:978-466-4396
Mailing Address - Fax:978-466-4029
Practice Address - Street 1:48 NELSON STREET
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-466-4396
Practice Address - Fax:978-466-4029
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205602363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0325601Medicaid
MA0325601Medicaid
MAPE NP3903Medicare ID - Type Unspecified