Provider Demographics
NPI:1225017734
Name:PETERSON, NICOLE E (PT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 PLEASANT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2136
Mailing Address - Country:US
Mailing Address - Phone:320-251-9717
Mailing Address - Fax:
Practice Address - Street 1:1245 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1802
Practice Address - Country:US
Practice Address - Phone:320-529-0036
Practice Address - Fax:320-259-0038
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7157225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist