Provider Demographics
NPI:1508000878
Name:PETERSEN, KIMBERLEY MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:MICHELLE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 COOPER ST APT 111
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-2036
Mailing Address - Country:US
Mailing Address - Phone:406-396-1019
Mailing Address - Fax:
Practice Address - Street 1:634 EDDY AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-6601
Practice Address - Country:US
Practice Address - Phone:406-243-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100360363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health