Healthcare Provider Details

I. General information

NPI: 1265952626
Provider Name (Legal Business Name): KIMBERLY PETERSON DNP, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 07/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

IV. Provider business mailing address

250 POLK ST
GARVIN MN
56132-9769
US

V. Phone/Fax

Practice location:
  • Phone: 507-537-9007
  • Fax: 507-537-9290
Mailing address:
  • Phone: 507-829-8392
  • Fax: 507-746-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5256
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1659719
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: