Healthcare Provider Details

I. General information

NPI: 1912086133
Provider Name (Legal Business Name): MYRNA JOY PETERS MSN, RN, C-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR
FAIRMONT MN
56031-4575
US

IV. Provider business mailing address

164 110TH ST
ALPHA MN
56111-1107
US

V. Phone/Fax

Practice location:
  • Phone: 507-238-8500
  • Fax:
Mailing address:
  • Phone: 507-764-3361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0914222
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2473
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: