Healthcare Provider Details

I. General information

NPI: 1508226226
Provider Name (Legal Business Name): TAWNI PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N BERKLEY ST
COUNCIL ID
83612
US

IV. Provider business mailing address

PO BOX 560
NEW MEADOWS ID
83654-0560
US

V. Phone/Fax

Practice location:
  • Phone: 208-250-0970
  • Fax:
Mailing address:
  • Phone: 209-825-0097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN-45114
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number54458
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: