Provider Demographics
NPI:1720406960
Name:PETERSEN, HEIKE (NP)
Entity Type:Individual
Prefix:
First Name:HEIKE
Middle Name:
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 1:525 HATHAWAY STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRPLAY
Mailing Address - State:CO
Mailing Address - Zip Code:80444
Mailing Address - Country:US
Mailing Address - Phone:719-836-0334
Mailing Address - Fax:
Practice Address - Street 1:525 HATHAWAY STREET
Practice Address - Street 2:
Practice Address - City:FAIRPLAY
Practice Address - State:CO
Practice Address - Zip Code:80440
Practice Address - Country:US
Practice Address - Phone:719-836-0334
Practice Address - Fax:719-836-0336
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0173599163W00000X
CO0995674363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse