Provider Demographics
NPI:1821191891
Name:PETERSON, LORI JEAN (NP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:PETERSON
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 1:1752 DORSET LN
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-2452
Mailing Address - Country:US
Mailing Address - Phone:715-246-8365
Mailing Address - Fax:715-246-8298
Practice Address - Street 1:1752 DORSET LN
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2452
Practice Address - Country:US
Practice Address - Phone:715-246-8365
Practice Address - Fax:715-246-8298
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI121689-30363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI363LW0102XOtherTAXONOMY