Provider Demographics
NPI:1700653664
Name:PETERSON, MICHELLE NICOLE (FNP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2797 N HWY 89 STE 100
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-1231
Mailing Address - Country:US
Mailing Address - Phone:801-528-7113
Mailing Address - Fax:
Practice Address - Street 1:2797 N HIGHWAY 89 STE 100
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-1231
Practice Address - Country:US
Practice Address - Phone:801-528-7113
Practice Address - Fax:801-782-6801
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10662515-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner