Provider Demographics
NPI:1821327263
Name:PETERSON, SALLY (LPN)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4054 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:WI
Mailing Address - Zip Code:53049-1694
Mailing Address - Country:US
Mailing Address - Phone:641-425-5187
Mailing Address - Fax:
Practice Address - Street 1:W4054 LINDEN DR
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:WI
Practice Address - Zip Code:53049-1694
Practice Address - Country:US
Practice Address - Phone:641-425-5187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP32556164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse