Provider Demographics
NPI:1154970879
Name:PETERSON, CASEY ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ELIZABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:E
Other - Last Name:BYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3512 STELLHORN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4631
Mailing Address - Country:US
Mailing Address - Phone:260-445-5646
Mailing Address - Fax:651-237-8774
Practice Address - Street 1:15022 BUTTERBOUGH LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-8833
Practice Address - Country:US
Practice Address - Phone:260-445-5646
Practice Address - Fax:651-237-8774
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009322A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily