Provider Demographics
NPI:1548326317
Name:PETERSEN, PAMELA H (CNM)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:H
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:10 BENTON AVENUE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-343-7614
Practice Address - Fax:845-343-5390
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000419176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355931Medicaid
NY00355931Medicaid