Provider Demographics
NPI:1326244203
Name:PETER, STEPHANIE JO (RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JO
Last Name:PETER
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7708
Mailing Address - Country:US
Mailing Address - Phone:843-364-4372
Mailing Address - Fax:
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 230
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
877167133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL95249Medicare UPIN