Provider Demographics
NPI:1710707641
Name:PETERSON, CHARITY FAITH (LPN)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:FAITH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:FAITH
Other - Last Name:KITTELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:705 STATE RD
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-2210
Mailing Address - Country:US
Mailing Address - Phone:320-226-9724
Mailing Address - Fax:
Practice Address - Street 1:814 N 11TH ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1629
Practice Address - Country:US
Practice Address - Phone:320-269-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN820913164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse