Provider Demographics
NPI:1770332199
Name:PETERSON, BROOKE ELSIE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELSIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 W DAYTON ST APT 211
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-2201
Mailing Address - Country:US
Mailing Address - Phone:715-299-1951
Mailing Address - Fax:
Practice Address - Street 1:3401 MAPLE GROVE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-5013
Practice Address - Country:US
Practice Address - Phone:608-845-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other