Provider Demographics
NPI:1225488174
Name:PETTERSON, NIKKI
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-218-2205
Mailing Address - Fax:606-432-0336
Practice Address - Street 1:1098 S MAYO TRL
Practice Address - Street 2:SUITE 103
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1546
Practice Address - Country:US
Practice Address - Phone:606-218-2205
Practice Address - Fax:606-432-0336
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY923068133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered