Healthcare Provider Details

I. General information

NPI: 1922536267
Provider Name (Legal Business Name): MCKENZIE REILE PETERSON DNP, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICK PETERSON DNP, APRN, FNP-C

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E MAIN AVE
BISMARCK ND
58501-4525
US

IV. Provider business mailing address

PO BOX 7433
BISMARCK ND
58507-7433
US

V. Phone/Fax

Practice location:
  • Phone: 701-502-4669
  • Fax: 833-608-1015
Mailing address:
  • Phone: 701-226-7586
  • Fax: 833-608-1015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR36156
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: