Provider Demographics
NPI:1164076345
Name:PETERSON, KATHERINE V (RD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:V
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W NORTH ST APT 26
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5142
Mailing Address - Country:US
Mailing Address - Phone:630-605-6265
Mailing Address - Fax:
Practice Address - Street 1:302 W NORTH ST APT 26
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5142
Practice Address - Country:US
Practice Address - Phone:630-605-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3414-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered