Healthcare Provider Details

I. General information

NPI: 1134298730
Provider Name (Legal Business Name): DEBORAH ANNE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 UNIVERSITY AVE W SUITE N385
SAINT PAUL MN
55104-2801
US

IV. Provider business mailing address

1821 UNIVERSITY AVE W SUITE N385
SAINT PAUL MN
55104-2801
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-8515
  • Fax: 651-644-3451
Mailing address:
  • Phone: 651-644-8515
  • Fax: 651-644-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: