Provider Demographics
NPI:1346794559
Name:PETERSEN, RACHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
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 1:10717 VIRGINIA PLZ STE 121
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-4229
Mailing Address - Country:US
Mailing Address - Phone:402-779-6558
Mailing Address - Fax:
Practice Address - Street 1:10707 PACIFIC ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4762
Practice Address - Country:US
Practice Address - Phone:402-397-7989
Practice Address - Fax:402-397-8703
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111943363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner