Provider Demographics
NPI:1366632192
Name:PETERSON, MELISSA M
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5773 RICHMOND DR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1605
Mailing Address - Country:US
Mailing Address - Phone:608-204-9862
Mailing Address - Fax:
Practice Address - Street 1:2725 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2288
Practice Address - Country:US
Practice Address - Phone:608-358-6489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7038949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist