Basic Information
| Provider Information | |||||||||
| NPI: | 1508020769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERLIN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | CANP/CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 2008004429 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | R164842-9 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2200X | R164842-9 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.