Provider Demographics
NPI:1508020769
Name:PETERLIN, STACY ANNE (CANP/CFNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANNE
Last Name:PETERLIN
Suffix:
Gender:F
Credentials:CANP/CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2008004429363LA2200X
MNR164842-9363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily