Provider Demographics
NPI:1619028578
Name:PETERSEN, CYNTHIA DENISE
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:DENISE
Last Name:PETERSEN
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 1:511 EDUCATION DR
Mailing Address - Street 2:
Mailing Address - City:MALCOLM
Mailing Address - State:NE
Mailing Address - Zip Code:68402-9573
Mailing Address - Country:US
Mailing Address - Phone:402-796-2422
Mailing Address - Fax:
Practice Address - Street 1:415 S 25TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-3654
Practice Address - Country:US
Practice Address - Phone:402-717-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE46338163W00000X
NE110796363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse