Provider Demographics
NPI:1487833448
Name:PETERSON, ELLEN W (FAMILY NP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FAMILY NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7962
Mailing Address - Fax:508-860-7929
Practice Address - Street 1:170 APRICOT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1225
Practice Address - Country:US
Practice Address - Phone:508-799-3346
Practice Address - Fax:508-755-8054
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily