Provider Demographics
NPI:1972800381
Name:PETERSON, COLLEEN ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:ANN
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 1:14990 91ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8831
Mailing Address - Country:US
Mailing Address - Phone:763-420-5759
Mailing Address - Fax:
Practice Address - Street 1:14990 91ST AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8831
Practice Address - Country:US
Practice Address - Phone:763-420-5759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR98713-6163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse