Provider Demographics
NPI:1588191043
Name:PETERSON, AMANDA (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, RDN, LDN
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 278
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-0278
Mailing Address - Country:US
Mailing Address - Phone:910-296-2747
Mailing Address - Fax:
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-8801
Practice Address - Country:US
Practice Address - Phone:910-296-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005094133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered