MEDICARE: MRS. ASHLEY ANN PETERSON APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	CNP 1650	MN

General Provider Information

NPI Number	:	1215303573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ASHLEY ANN PETERSON APRN

Provider Business Mailing Address
First Line	:	4464 RALSTON DR
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-1519
Country	:	US
Telephone Number	:	218-722-8634
Fax Number	:

Provider Business Practice Location Address
First Line	:	4464 RALSTON DR
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-1519
Country	:	US
Telephone Number	:	218-722-8634
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	08/20/2015

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