Provider Demographics
NPI:1740700368
Name:PETERSEN, LENA CAROLINE (NP)
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:CAROLINE
Last Name:PETERSEN
Suffix:
Gender:
Credentials:NP
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 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-543-6979
Mailing Address - Fax:
Practice Address - Street 1:1225 E CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-1225
Practice Address - Country:US
Practice Address - Phone:479-795-1301
Practice Address - Fax:479-795-1304
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY716670-1163W00000X
NY342629363LF0000X
AR230416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty