Provider Demographics
NPI:1700908696
Name:FITZGERALD-PETERSEN, KATHLEEN ELAINE (MSN, RN, WHNP-BC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELAINE
Last Name:FITZGERALD-PETERSEN
Suffix:
Gender:F
Credentials:MSN, RN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-1810
Mailing Address - Country:US
Mailing Address - Phone:937-374-5600
Mailing Address - Fax:
Practice Address - Street 1:360 WILSON DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1810
Practice Address - Country:US
Practice Address - Phone:937-374-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07736363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2776063Medicaid
OHH507480Medicare PIN
OH2776063Medicaid