Provider Demographics
NPI:1225302672
Name:PETERSON, ELISABETH C (RD)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:C
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 1:2306 BOULDER RUN CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-3644
Mailing Address - Country:US
Mailing Address - Phone:804-440-3110
Mailing Address - Fax:804-377-9690
Practice Address - Street 1:2200 PUMP RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-3539
Practice Address - Country:US
Practice Address - Phone:804-440-3110
Practice Address - Fax:804-377-9690
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA839987133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered