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General NPI Number Information
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NPI Number | 1194280156
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Entity Type | Individual
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Provider Name | ANDRIA JO PETERSEN NP-C
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Gender | Female
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Dates
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Enumeration Date | 02/04/2019
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Last Update Date | 06/10/2019
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Provider Practice Location Address
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Address Line | 2400 W 49TH ST
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City | SIOUX FALLS
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State | SD
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Zip | 57105-6581
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Country | US
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Telephone | 605-312-8700
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Fax | 605-312-8700
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Provider Business Mailing Address
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Address Line | 2400 W 49TH ST
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City | SIOUX FALLS
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State | SD
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Zip | 57105-6581
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Country | US
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Telephone | 605-312-8700
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Fax | 605-312-8700
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | CP001529
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CP001529
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License Number State | SD
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