Provider Demographics
NPI:1669987111
Name:PETERSON, VANESSA MAE
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 OSPREY PLACE NW
Mailing Address - Street 2:
Mailing Address - City:STEWARTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55976
Mailing Address - Country:US
Mailing Address - Phone:507-993-2004
Mailing Address - Fax:
Practice Address - Street 1:2012 OSPREY PLACE NW
Practice Address - Street 2:
Practice Address - City:STEWARTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55976
Practice Address - Country:US
Practice Address - Phone:507-993-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1089962-1-AFC253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency