Provider Demographics
NPI:1508226226
Name:PETERSON, TAWNI
Entity Type:Individual
Prefix:
First Name:TAWNI
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:
Mailing Address - City:NEW MEADOWS
Mailing Address - State:ID
Mailing Address - Zip Code:83654-0560
Mailing Address - Country:US
Mailing Address - Phone:209-825-0097
Mailing Address - Fax:
Practice Address - Street 1:205 N BERKLEY ST
Practice Address - Street 2:
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612
Practice Address - Country:US
Practice Address - Phone:208-250-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-45114163W00000X
ID54458363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse