Provider Demographics
NPI:1790514461
Name:PETERSON, EDNA PEARLEEANNE (CNA)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:PEARLEEANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 5TH ST NW APT 14
Mailing Address - Street 2:
Mailing Address - City:DILWORTH
Mailing Address - State:MN
Mailing Address - Zip Code:56529-1086
Mailing Address - Country:US
Mailing Address - Phone:218-880-1520
Mailing Address - Fax:
Practice Address - Street 1:112 UNIVERSITY DR N STE L140
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4635
Practice Address - Country:US
Practice Address - Phone:218-880-1520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND143356376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide