Basic Information
| Provider Information | |||||||||
| NPI: | 1639191075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 S ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540249449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830539 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 S ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540249449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 66586 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 66586 | 01 | WI | STATE LICENCE | OTHER | 235E7PE | 01 | MN | BLUE CROSS CLINIC | OTHER | HP69858 | 01 | WI | HEALTHPARTNERS | OTHER | 093660100 | 05 | MN | MEDICAID | 01 24269 | 01 | WI | MEDICA | OTHER | 36007300 | 05 | WI | MEDICAID | NA9031047699 | 01 | WI | PREFERRED ONE | OTHER |