Provider Demographics
NPI:1124005236
Name:PETERSON, ADALINE LEE (ARNP)
Entity Type:Individual
Prefix:
First Name:ADALINE
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 W DALE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1901
Mailing Address - Country:US
Mailing Address - Phone:319-235-5086
Mailing Address - Fax:319-235-5107
Practice Address - Street 1:146 W DALE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1901
Practice Address - Country:US
Practice Address - Phone:319-235-5086
Practice Address - Fax:319-235-5107
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF-034796363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2419234Medicaid
IA0419234Medicaid
IA3419234Medicaid
IA3419234Medicaid
IA2419234Medicaid