Provider Demographics
NPI:1588095376
Name:PETERSON, CHRISITNE (NNP)
Entity type:Individual
Prefix:
First Name:CHRISITNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3337
Mailing Address - Country:US
Mailing Address - Phone:801-357-7707
Mailing Address - Fax:
Practice Address - Street 1:1034 W 500 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2537
Practice Address - Country:US
Practice Address - Phone:801-357-7707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT199990-4405363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care