Provider Demographics
NPI:1457732414
Name:PETERSEN, KIZZY HARGETT (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:KIZZY
Middle Name:HARGETT
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:KIZZY
Other - Middle Name:LABRETT
Other - Last Name:HARGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14920
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-4920
Mailing Address - Country:US
Mailing Address - Phone:252-675-4600
Mailing Address - Fax:252-262-6306
Practice Address - Street 1:2002 S GLENBURNIE RD STE 4C
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5230
Practice Address - Country:US
Practice Address - Phone:252-675-4600
Practice Address - Fax:252-262-6306
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007734363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1457732414Medicaid