Provider Demographics
NPI:1659940351
Name:PETERSEN, ELIZA MCCALL (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:MCCALL
Last Name:PETERSEN
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 1:147 NC HIGHWAY 24 STE 101
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-8982
Mailing Address - Country:US
Mailing Address - Phone:252-648-8777
Mailing Address - Fax:
Practice Address - Street 1:147 NC HIGHWAY 24 STE 101
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-8982
Practice Address - Country:US
Practice Address - Phone:252-648-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006421133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered