Provider Demographics
NPI:1134845647
Name:PETERSON, PATRICIA GAIL (RN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:GAIL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:GAIL
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:2200 RANDALLIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4638
Mailing Address - Country:US
Mailing Address - Phone:260-373-1000
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-266-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28157874A163WX0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28157874AOtherREGISTERED NURSE