Provider Demographics
NPI:1669498390
Name:PETERSON, TAMMY FAYE
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:FAYE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 S CRATER RD
Mailing Address - Street 2:STE.B
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9211
Mailing Address - Country:US
Mailing Address - Phone:804-733-6960
Mailing Address - Fax:
Practice Address - Street 1:3400 S CRATER RD
Practice Address - Street 2:STE.B
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9211
Practice Address - Country:US
Practice Address - Phone:804-733-6960
Practice Address - Fax:804-733-3880
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered