Provider Demographics
NPI:1073063905
Name:PETERSEN, ERICKA LESLIE (CNP)
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:LESLIE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAC LN
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-3391
Mailing Address - Country:US
Mailing Address - Phone:605-224-5901
Mailing Address - Fax:
Practice Address - Street 1:100 MAC LN
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3391
Practice Address - Country:US
Practice Address - Phone:605-224-5901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily