Provider Demographics
NPI:1497231369
Name:PETERSON, SAMANTHA (MS, RD, CSO)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, RD, CSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12242 S 185TH AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3007
Practice Address - Country:US
Practice Address - Phone:623-256-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered