Healthcare Provider Details

I. General information

NPI: 1487626719
Provider Name (Legal Business Name): TONJA S PETERSEN - ANDERSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 W MAIN ST
LAKE CITY IA
51449-1585
US

IV. Provider business mailing address

1351 W MAIN ST PO BOX 114
LAKE CITY IA
51449-1585
US

V. Phone/Fax

Practice location:
  • Phone: 712-464-7907
  • Fax: 712-464-7412
Mailing address:
  • Phone: 712-464-7907
  • Fax: 712-464-7412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA097418
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: