Provider Demographics
NPI:1114231362
Name:PETERSEN, KERRY LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 N 185TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3834
Mailing Address - Country:US
Mailing Address - Phone:402-578-4965
Mailing Address - Fax:
Practice Address - Street 1:987440 NEBRASKA MEDICAL CTR
Practice Address - Street 2:NEONATAL INTENSIVE CARE UNIT
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-7740
Practice Address - Country:US
Practice Address - Phone:402-559-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111154364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal