Provider Demographics
NPI:1356649180
Name:PETERSON, ROXANNE L (RN)
Entity Type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2849 227TH LN NE
Mailing Address - Street 2:
Mailing Address - City:EAST BETHEL
Mailing Address - State:MN
Mailing Address - Zip Code:55005-9208
Mailing Address - Country:US
Mailing Address - Phone:763-434-0747
Mailing Address - Fax:
Practice Address - Street 1:2849 227TH LN NE
Practice Address - Street 2:
Practice Address - City:EAST BETHEL
Practice Address - State:MN
Practice Address - Zip Code:55005-9208
Practice Address - Country:US
Practice Address - Phone:763-434-0747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 160305-3163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health