Provider Demographics
NPI:1467598367
Name:PETERSON, JOYCE MONICA (RN)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:MONICA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12160 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2218
Mailing Address - Country:US
Mailing Address - Phone:262-242-0291
Mailing Address - Fax:262-242-0291
Practice Address - Street 1:12160 N RIVER RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-2218
Practice Address - Country:US
Practice Address - Phone:262-242-0291
Practice Address - Fax:262-242-0291
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58491-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38223000Medicaid