1942572086 NPI number — TRICHELLE GRACE PETERMANN CNP

Table of content: TRICHELLE GRACE PETERMANN CNP (NPI 1942572086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942572086 NPI number — TRICHELLE GRACE PETERMANN CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERMANN
Provider First Name:
TRICHELLE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942572086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5527 STEWART ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32570-4303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 E 20TH ST
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-332-2240
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  CP000680 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6837130 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108457900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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