Provider Demographics
NPI:1659881597
Name:PETERSEN, CRYSTAL LYNN (RDN, LD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 C AVE
Mailing Address - Street 2:
Mailing Address - City:GLADBROOK
Mailing Address - State:IA
Mailing Address - Zip Code:50635-9356
Mailing Address - Country:US
Mailing Address - Phone:319-239-4352
Mailing Address - Fax:
Practice Address - Street 1:201 E J AVE
Practice Address - Street 2:
Practice Address - City:GRUNDY CENTER
Practice Address - State:IA
Practice Address - Zip Code:50638-2028
Practice Address - Country:US
Practice Address - Phone:319-824-5421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00703133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered