Provider Demographics
NPI:1841443272
Name:PETERSON, WENDY R (CFNP)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 HIGHWAY 190 EAST SERVICE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4960
Mailing Address - Country:US
Mailing Address - Phone:985-893-9592
Mailing Address - Fax:985-318-1004
Practice Address - Street 1:7015 HIGHWAY 190 EAST SERVICE RD STE 102
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4960
Practice Address - Country:US
Practice Address - Phone:985-893-9592
Practice Address - Fax:985-318-1004
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860436363LF0000X
LAAP07310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2345940Medicaid
MS02078279Medicaid
LA2345940Medicaid