Provider Demographics
NPI:1639068026
Name:PETERSON, LEISA ANNE (APRN)
Entity type:Individual
Prefix:
First Name:LEISA
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 100TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ANTLER
Mailing Address - State:ND
Mailing Address - Zip Code:58711-9728
Mailing Address - Country:US
Mailing Address - Phone:701-240-2264
Mailing Address - Fax:
Practice Address - Street 1:2730 100TH ST NW
Practice Address - Street 2:
Practice Address - City:ANTLER
Practice Address - State:ND
Practice Address - Zip Code:58711-9728
Practice Address - Country:US
Practice Address - Phone:701-240-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND202900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily