Provider Demographics
NPI:1598195778
Name:PETERSON, GAIL
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POLK COUNTY PLZ
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BALSAM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54810-9071
Mailing Address - Country:US
Mailing Address - Phone:715-485-8500
Mailing Address - Fax:715-485-8501
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:SUITE 180
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8500
Practice Address - Fax:715-485-8501
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77261-30163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health