Provider Demographics
NPI:1700041472
Name:PETERSEN, MICHELLE K (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:920-793-7400
Mailing Address - Fax:
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241
Practice Address - Country:US
Practice Address - Phone:920-793-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8589-033363L00000X
WI8589-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080774Medicaid