MEDICARE: CALISTA PETERSON

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	163W00000X	Registered Nurse	R037676	SD

General Provider Information

NPI Number	:	1578400107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALISTA PETERSON

Provider Business Mailing Address
First Line	:	3609 HALL ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3609 HALL ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2225
Country	:	US
Telephone Number	:	605-431-6613
Fax Number	:

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

Provider Enumeration Date	:	05/01/2026
Last Update Date	:	05/01/2026

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Directions to “ CALISTA PETERSON ” Practice Location

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