Healthcare Provider Details

I. General information

NPI: 1922463462
Provider Name (Legal Business Name): SHERRIE PETERSON RN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4227 9TH AVE S
FARGO ND
58103-2018
US

IV. Provider business mailing address

4227 9TH AVE S
FARGO ND
58103-2018
US

V. Phone/Fax

Practice location:
  • Phone: 701-282-6561
  • Fax:
Mailing address:
  • Phone: 701-282-6561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR20492
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: