Provider Demographics
NPI:1760757744
Name:PETERSON, AMY A (MS)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 NORTHERN SKY DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8534
Mailing Address - Country:US
Mailing Address - Phone:701-751-6336
Mailing Address - Fax:
Practice Address - Street 1:4501 COLEMAN ST STE 103
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0996
Practice Address - Country:US
Practice Address - Phone:701-751-6336
Practice Address - Fax:701-751-6337
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55542Medicaid