Provider Demographics
NPI:1689216095
Name:PETERSON, MACHELLE F (CNM)
Entity Type:Individual
Prefix:
First Name:MACHELLE
Middle Name:F
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:TENSED
Mailing Address - State:ID
Mailing Address - Zip Code:83870-0093
Mailing Address - Country:US
Mailing Address - Phone:208-874-3095
Mailing Address - Fax:833-900-1404
Practice Address - Street 1:468 LONESOME DOVE LN
Practice Address - Street 2:
Practice Address - City:TENSED
Practice Address - State:ID
Practice Address - Zip Code:83870-8387
Practice Address - Country:US
Practice Address - Phone:208-874-3095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61016081367A00000X
ID62928367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID62928OtherCNM PROVIDER LICENSE