Provider Demographics
NPI:1417039652
Name:PETERSEN, DEBRA ANTOINETTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANTOINETTE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8918 BLAINE PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8102
Mailing Address - Country:US
Mailing Address - Phone:219-365-2368
Mailing Address - Fax:219-365-2408
Practice Address - Street 1:7131 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324
Practice Address - Country:US
Practice Address - Phone:219-845-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28063616A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily