Provider Demographics
NPI:1619386455
Name:PETTERSON, NICHOLE (FNP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:600 SW COLUMBIA ST STE 6250
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:541-383-1883
Practice Address - Street 1:1250 SW VETERANS WAY STE 120
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2588
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5816363LF0000X
OR202009378NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily