Provider Demographics
NPI:1457634214
Name:PETERSON, NICOLE E (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 N TEUTONIA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7171 N TEUTONIA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2319
Practice Address - Country:US
Practice Address - Phone:414-351-2538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14265-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist