Provider Demographics
NPI:1134819535
Name:PETERSEN, DANIELLE ELAINE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ELAINE
Last Name:PETERSEN
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:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:
Practice Address - Street 1:5950 UNIVERSITY AVE STE 380
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8289
Practice Address - Country:US
Practice Address - Phone:515-875-9908
Practice Address - Fax:515-875-9882
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IA130557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant