Provider Demographics
NPI:1043029457
Name:PETERSEN, ALEXIS GUNDERSEN (FNP)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:GUNDERSEN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6048 S HAZELHURST DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-5108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6048 S HAZELHURST DR
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-5108
Practice Address - Country:US
Practice Address - Phone:801-560-9124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-01
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9252507-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily