Provider Demographics
NPI:1689748667
Name:BRUNEAU PETERSEN, KIMBERLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:BRUNEAU PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33296 LONE PINE DR
Mailing Address - Street 2:
Mailing Address - City:BROWERVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56438-5108
Mailing Address - Country:US
Mailing Address - Phone:708-341-1891
Mailing Address - Fax:
Practice Address - Street 1:33296 LONE PINE DR
Practice Address - Street 2:
Practice Address - City:BROWERVILLE
Practice Address - State:MN
Practice Address - Zip Code:56438-5108
Practice Address - Country:US
Practice Address - Phone:708-341-1891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73796207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074956Medicaid
IL036074956Medicaid
ILL83647Medicare ID - Type Unspecified
IL036074956Medicaid