Provider Demographics
NPI:1184162240
Name:PETERSON, STEPHENIE JEAN (RN)
Entity type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STEPHENIE
Other - Middle Name:JEAN
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:17138 W STATE ROAD 11
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520-9735
Mailing Address - Country:US
Mailing Address - Phone:608-558-5756
Mailing Address - Fax:
Practice Address - Street 1:17138 W STATE ROAD 11
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-9735
Practice Address - Country:US
Practice Address - Phone:608-558-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI168557-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse