Provider Demographics
NPI:1215260831
Name:PETERSON, SARAH LEE (RN)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SARAH
Other - Middle Name:LEE
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:253 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-2734
Mailing Address - Country:US
Mailing Address - Phone:920-251-1409
Mailing Address - Fax:
Practice Address - Street 1:253 FOREST ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010-2734
Practice Address - Country:US
Practice Address - Phone:920-251-1409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI159129-030163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice