Provider Demographics
NPI:1598042285
Name:PETERSEN KUEMMEL, AMBER N (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:N
Last Name:PETERSEN KUEMMEL
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:N
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, CRNA
Mailing Address - Street 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:920-965-4055
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-3388
Practice Address - Fax:920-288-3370
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI159301163W00000X
WI089867367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1598042285Medicaid
WI71460Medicare PIN
WI07650Medicare PIN
WI714600085Medicare PIN