Provider Demographics
NPI:1396375903
Name:PETERSON, EMMA LOUISE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:LOUISE
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 1:19520 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-2760
Mailing Address - Country:US
Mailing Address - Phone:402-699-0329
Mailing Address - Fax:
Practice Address - Street 1:5000 SAINT PAUL AVE # SMB9020
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-2760
Practice Address - Country:US
Practice Address - Phone:402-699-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program