Provider Demographics
NPI:1356358022
Name:PETERSON KLEIN, NANCY (OD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:PETERSON KLEIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:PETERSON
Other - Last Name:UNIACKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1310 CRAMER CIRCLE
Mailing Address - Street 2:PENNOCK 506
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2738
Mailing Address - Country:US
Mailing Address - Phone:231-591-2222
Mailing Address - Fax:231-591-3991
Practice Address - Street 1:1310 CRAMER CIRCLE
Practice Address - Street 2:PENNOCK 506
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2738
Practice Address - Country:US
Practice Address - Phone:231-591-2222
Practice Address - Fax:231-591-3991
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4401705Medicaid
MINP002580OtherBLUE CROSS
U29916Medicare UPIN
MI0784610001Medicare NSC
MI4401705Medicaid