Provider Demographics
NPI:1306568654
Name:PETERSEN, STACEY RAE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:RAE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 LINCOLN ST NE
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-3311
Mailing Address - Country:US
Mailing Address - Phone:712-546-7871
Mailing Address - Fax:
Practice Address - Street 1:899 E 12TH STREET APT 9453
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50304-5030
Practice Address - Country:US
Practice Address - Phone:712-541-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA171201363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily