Provider Demographics
NPI:1679987432
Name:PETERSEN, MOLLY (APRN)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12077 ELMWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007
Mailing Address - Country:US
Mailing Address - Phone:402-332-7648
Mailing Address - Fax:
Practice Address - Street 1:17670 WELCH PLZ STE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3805
Practice Address - Country:US
Practice Address - Phone:402-403-5222
Practice Address - Fax:402-403-5233
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111672363L00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily