Provider Demographics
NPI:1508235326
Name:PETERSEN, ELLEN LOUISE KLINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LOUISE KLINE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14617 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-1416
Mailing Address - Country:US
Mailing Address - Phone:888-227-3312
Mailing Address - Fax:
Practice Address - Street 1:14617 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-1416
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201506508NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily