Provider Demographics
NPI:1871257741
Name:PETERSON, MICHELLE DAWN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1131
Mailing Address - Country:US
Mailing Address - Phone:502-647-4668
Mailing Address - Fax:
Practice Address - Street 1:615 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1131
Practice Address - Country:US
Practice Address - Phone:502-647-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily