Provider Demographics
NPI:1912086133
Name:PETERS, MYRNA JOY (MSN, RN, C-FNP)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:JOY
Last Name:PETERS
Suffix:
Gender:F
Credentials:MSN, RN, C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 110TH ST
Mailing Address - Street 2:
Mailing Address - City:ALPHA
Mailing Address - State:MN
Mailing Address - Zip Code:56111-1107
Mailing Address - Country:US
Mailing Address - Phone:507-764-3361
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0914222363LF0000X
MN2473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN211519100Medicaid
MNS48477Medicare UPIN