Provider Demographics
NPI:1255335030
Name:PETERSON, JOANNE M (NP)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N66W25201 COUNTY HIGHWAY VV
Mailing Address - Street 2:FAST CARE CLINIC
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-2677
Mailing Address - Country:US
Mailing Address - Phone:262-532-8691
Mailing Address - Fax:
Practice Address - Street 1:N66W25201 COUNTY HIGHWAY VV
Practice Address - Street 2:FAST CARE CLINIC
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-2677
Practice Address - Country:US
Practice Address - Phone:262-532-8691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255335030Medicaid
43859300OtherMEDICAID
S53287Medicare UPIN
001030080Medicare ID - Type Unspecified
WI1255335030Medicaid
WI73-601 1246Medicare PIN