Provider Demographics
NPI:1154066108
Name:WISELEY-PETERSON, ALICIA JOY (RN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JOY
Last Name:WISELEY-PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:WISELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20649 RIDER RD
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MN
Mailing Address - Zip Code:56455-2099
Mailing Address - Country:US
Mailing Address - Phone:218-513-5999
Mailing Address - Fax:
Practice Address - Street 1:20649 RIDER RD
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MN
Practice Address - Zip Code:56455-2099
Practice Address - Country:US
Practice Address - Phone:218-513-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN160182-2163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse