Provider Demographics
NPI:1508265331
Name:PETERSON, KATIE MARIE (AGNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3931 LOUISIANA AVE S
Practice Address - Street 2:SUITE E202
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-5000
Practice Address - Country:US
Practice Address - Phone:952-993-9184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNAG0614152363LG0600X
MN3298363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology