Provider Demographics
NPI:1871481705
Name:PETERSEN, MICHELLE KAY
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KAY
Last Name:PETERSEN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3802
Mailing Address - Country:US
Mailing Address - Phone:815-719-2625
Mailing Address - Fax:
Practice Address - Street 1:813 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3802
Practice Address - Country:US
Practice Address - Phone:815-719-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide