Provider Demographics
NPI:1982437695
Name:PETERSDORFF, EMILY ANN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:PETERSDORFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANN
Other - Last Name:MCCULLOH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N14W23777 STONE RIDGE DR STE 8ITE135
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1158
Mailing Address - Country:US
Mailing Address - Phone:414-446-0751
Mailing Address - Fax:
Practice Address - Street 1:N14W23777 STONE RIDGE DR STE 135
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1164
Practice Address - Country:US
Practice Address - Phone:414-446-0751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program