Provider Demographics
NPI:1407906704
Name:PETERSEN, LORI A (NP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3925
Mailing Address - Country:US
Mailing Address - Phone:603-577-2039
Mailing Address - Fax:603-882-5656
Practice Address - Street 1:8 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3925
Practice Address - Country:US
Practice Address - Phone:603-577-2039
Practice Address - Fax:603-882-5656
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214795363L00000X
NH069512-23363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110019301AMedicaid
MANP364701Medicare PIN
MAP47887Medicare UPIN