Provider Demographics
NPI:1023309804
Name:PETERSON, CAROL JEAN (APNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:JEAN
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7238
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-445-7222
Practice Address - Fax:920-445-7238
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4378-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI590050059Medicare Oscar/Certification
WIWI1119014Medicare Oscar/Certification
WI430751201Medicare Oscar/Certification
WI078450064Medicare Oscar/Certification
WI71700064Medicare Oscar/Certification
WI075100136Medicare Oscar/Certification
WI07028Medicare PIN
WI007170064Medicare Oscar/Certification
WI8002100039Medicare Oscar/Certification