Healthcare Provider Details

I. General information

NPI: 1114153863
Provider Name (Legal Business Name): CAROL VIRGINIA PETERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MALL DR
DULUTH MN
55811-3849
US

IV. Provider business mailing address

1700 MALL DR
DULUTH MN
55811-3849
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-0990
  • Fax: 218-491-7050
Mailing address:
  • Phone: 218-727-0990
  • Fax: 218-491-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number133133-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: