Provider Demographics
NPI:1477311280
Name:PETERSEN, PAITYN LANA (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:PAITYN
Middle Name:LANA
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:PAITYN
Other - Middle Name:LANA
Other - Last Name:RIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W1571 HUNTERS LN
Mailing Address - Street 2:
Mailing Address - City:HELENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53137-9773
Mailing Address - Country:US
Mailing Address - Phone:262-424-8120
Mailing Address - Fax:
Practice Address - Street 1:312 S 7TH ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1964
Practice Address - Country:US
Practice Address - Phone:262-728-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15140-33363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health