Provider Demographics
NPI:1528303252
Name:PETERSEN, AMBER M (LPN NURSE)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LPN NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-2913
Mailing Address - Country:US
Mailing Address - Phone:866-308-9925
Mailing Address - Fax:870-741-4784
Practice Address - Street 1:724 N SPRING ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2913
Practice Address - Country:US
Practice Address - Phone:866-308-9925
Practice Address - Fax:870-741-4784
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARLTP006546164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse