Provider Demographics
NPI:1750969705
Name:PETERSON, KATHRYN MARY (APRN)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 MIX AVE APT 506
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-2113
Mailing Address - Country:US
Mailing Address - Phone:203-848-8774
Mailing Address - Fax:
Practice Address - Street 1:1952 WHITNEY AVE STE 14
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-1209
Practice Address - Country:US
Practice Address - Phone:203-776-4444
Practice Address - Fax:203-776-4441
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9254363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health