Provider Demographics
NPI:1497147417
Name:PETERSON, NICOLE MONET (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MONET
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 1:4775 LARIMER PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9022
Mailing Address - Country:US
Mailing Address - Phone:970-461-9101
Mailing Address - Fax:970-461-9089
Practice Address - Street 1:4775 LARIMER PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-9022
Practice Address - Country:US
Practice Address - Phone:970-461-9101
Practice Address - Fax:970-461-9089
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19145183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist