Provider Demographics
NPI:1447682885
Name:PETERSON, MICHELLE JOAN (RN CAGNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JOAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN CAGNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:JOAN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR168705-3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1447682885Medicaid
H400102059Medicare PIN