Provider Demographics
NPI:1518465707
Name:PETERSEN, HANNAH KALEIGH (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:HANNAH
Middle Name:KALEIGH
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1052
Mailing Address - Country:US
Mailing Address - Phone:618-281-2233
Mailing Address - Fax:618-281-2244
Practice Address - Street 1:123 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1052
Practice Address - Country:US
Practice Address - Phone:618-281-2233
Practice Address - Fax:618-281-2244
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012007085163W00000X
MO2017036299363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse