Provider Demographics
NPI:1922536267
Name:PETERSON, MCKENZIE REILE (DNP, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:REILE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DNP, APRN, FNP-C
Other - Prefix:
Other - First Name:MICK
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP, APRN, FNP-C
Mailing Address - Street 1:PO BOX 7433
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58507-7433
Mailing Address - Country:US
Mailing Address - Phone:701-226-7586
Mailing Address - Fax:833-608-1015
Practice Address - Street 1:705 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4525
Practice Address - Country:US
Practice Address - Phone:701-502-4669
Practice Address - Fax:833-608-1015
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR36156363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily