Provider Demographics
NPI:1689163222
Name:PETERSEN, AMANDA (FNP-BC, RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:FNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POLE LINE RD W STE 113
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5819
Mailing Address - Country:US
Mailing Address - Phone:208-814-8292
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 113
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5819
Practice Address - Country:US
Practice Address - Phone:208-814-8292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58323363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily