Provider Demographics
NPI:1023569696
Name:PETERSON, CAROLYN N (RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:N
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 WAYBRIDGE LN
Mailing Address - Street 2:APT 1E
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-5769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 WAYBRIDGE LN
Practice Address - Street 2:APT 1E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-5769
Practice Address - Country:US
Practice Address - Phone:614-570-2878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004700133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered