Provider Demographics
NPI:1932343001
Name:PETERSON, NICOLE ELIZABETH (ARNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 305TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMA
Mailing Address - State:IA
Mailing Address - Zip Code:52339-9698
Mailing Address - Country:US
Mailing Address - Phone:641-484-4094
Mailing Address - Fax:641-484-2432
Practice Address - Street 1:1646 305TH ST
Practice Address - Street 2:
Practice Address - City:TAMA
Practice Address - State:IA
Practice Address - Zip Code:52339-9698
Practice Address - Country:US
Practice Address - Phone:641-484-4094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAJ-115527363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology