Provider Demographics
NPI:1639603913
Name:PETERSON, NICOLE MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 MONTCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1829
Mailing Address - Country:US
Mailing Address - Phone:847-322-9331
Mailing Address - Fax:
Practice Address - Street 1:2251 N SHORE DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:800-866-8673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015918363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner