Provider Demographics
NPI:1831397223
Name:PETERSON, NICOLE DIANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DIANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:DIANE
Other - Last Name:BLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:39142 CO HWY 19
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:MN
Mailing Address - Zip Code:56518
Mailing Address - Country:US
Mailing Address - Phone:218-385-2898
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0559933164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse