Provider Demographics
NPI:1235616269
Name:PETERSEN, KATHRYN LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LYNN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:L
Other - Last Name:ROETHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE STE 501
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-433-6050
Practice Address - Fax:920-433-6049
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI168554-30163W00000X
WI8598-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse