Kelly Petersen, RD
Dietitian, Registered in Chubbuck, ID. Individual provider (NPI-1).
NPI number1407637101
StatusActive
Last updated in NPPESOct 9, 2023
Details
- NPI
- 1407637101
- Entity type
- Individual (NPI-1)
- Name
- Kelly Petersen
- Credential
- RD
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- Oct 9, 2023
- Certification date
- Oct 9, 2023
- Last updated
- Oct 9, 2023
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 133V00000X | Dietitian, Registered | – | – | Yes |
Practice location
841 McKay StChubbuck, ID 83202-4961
Phone 208-705-5553
Mailing address
3724 Jefferson St Ste 104Austin, TX 78731-6204
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