Provider Demographics
NPI:1770244238
Name:PETERSON, PAMELA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-1705
Mailing Address - Country:US
Mailing Address - Phone:605-673-9460
Mailing Address - Fax:605-673-3618
Practice Address - Street 1:1220 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1705
Practice Address - Country:US
Practice Address - Phone:605-673-9460
Practice Address - Fax:605-673-3618
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator