Provider Demographics
NPI:1689680084
Name:PETERSEN, SHIRLEY MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MARIE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 PARK RD
Mailing Address - Street 2:
Mailing Address - City:GREENLEAF
Mailing Address - State:WI
Mailing Address - Zip Code:54126-9666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1658
Practice Address - Country:US
Practice Address - Phone:920-831-0070
Practice Address - Fax:920-831-7939
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16432-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16432-031OtherLPN