Provider Demographics
NPI:1003621137
Name:PETERSON, MANDY JO
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:JO
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:JO
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSN, RN, PHN
Mailing Address - Street 1:1936 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4968
Mailing Address - Country:US
Mailing Address - Phone:320-309-0679
Mailing Address - Fax:
Practice Address - Street 1:15 RIVERSIDE DR NE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0435
Practice Address - Country:US
Practice Address - Phone:320-309-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1608485163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty