Provider Demographics
NPI:1346206323
Name:PETERSHACK, KIM L (CD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:PETERSHACK
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1911
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-283-7192
Practice Address - Street 1:1313 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1911
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-283-7192
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1948OtherDEAN HEALTH INSURANCE
P50897Medicare UPIN