Provider Demographics
NPI:1417421264
Name:PETERSEN, KRISTIN RENE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:RENE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:RENE
Other - Last Name:OPPERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7850 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48746-9520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7850 BARNES RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:MI
Practice Address - Zip Code:48746-9520
Practice Address - Country:US
Practice Address - Phone:989-385-0957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009377208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation