Healthcare Provider Details

I. General information

NPI: 1700404274
Provider Name (Legal Business Name): RILEY WAYNE PETERSEN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 11/27/2023
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W BLDG A
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-812-5033
  • Fax: 801-812-5034
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5202116-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5202116-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: