Provider Demographics
NPI:1609141209
Name:PETERSEN, LISA (NURSE)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1727
Mailing Address - Country:US
Mailing Address - Phone:718-720-7961
Mailing Address - Fax:718-720-7961
Practice Address - Street 1:191 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1727
Practice Address - Country:US
Practice Address - Phone:718-720-7961
Practice Address - Fax:718-720-7961
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY571817-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse