Provider Demographics
NPI:1477288207
Name:PETERSEN, NANETTE (IBCLC)
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:NANETTE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:716 PHILLIPS LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4594
Mailing Address - Country:US
Mailing Address - Phone:704-677-8004
Mailing Address - Fax:
Practice Address - Street 1:716 PHILLIPS LN
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4594
Practice Address - Country:US
Practice Address - Phone:704-677-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL23003174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN