Provider Demographics
NPI:1669083382
Name:PETERSEN, ANDREA NICOLE (DNP, FNP)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:NICOLE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 LA GRAND DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7965
Mailing Address - Country:US
Mailing Address - Phone:660-596-1605
Mailing Address - Fax:
Practice Address - Street 1:2410 S LIMIT AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-6910
Practice Address - Country:US
Practice Address - Phone:573-814-1170
Practice Address - Fax:573-530-1037
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020026948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily