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General NPI Number Information
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NPI Number | 1245019694
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Entity Type | Individual
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Provider Name | MARIAH PETERSON CNP
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Gender | Female
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Dates
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Enumeration Date | 09/25/2023
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Last Update Date | 11/07/2024
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Provider Practice Location Address
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Address Line | 212 N PRAIRIE ST
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City | FLANDREAU
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State | SD
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Zip | 57028-1243
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Country | US
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Telephone | 605-997-2433
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Fax |
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Provider Business Mailing Address
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Address Line | 212 N PRARIE ST
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City | FLANDREAU
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State | SD
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Zip | 57028
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Country | US
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Telephone | 605-579-0283
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CP002971
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | R051425
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License Number State | SD
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