Provider Demographics
NPI:1821047754
Name:PETERSON, KATHY JEAN (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-6738
Mailing Address - Country:US
Mailing Address - Phone:719-488-6998
Mailing Address - Fax:719-488-8270
Practice Address - Street 1:192 FRONT ST
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-6738
Practice Address - Country:US
Practice Address - Phone:719-488-6998
Practice Address - Fax:719-488-8270
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO125210363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics