Provider Demographics
NPI:1972140804
Name:PETERSON, MAELEY ROSE (NNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MAELEY
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:MS
Other - First Name:MAELEY
Other - Middle Name:ROSE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:7649 CHAPPELLE WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-1681
Mailing Address - Country:US
Mailing Address - Phone:916-390-5085
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-703-3050
Practice Address - Fax:916-703-3055
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012668363LN0000X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal