Provider Demographics
NPI:1689916660
Name:PEACH, JODY (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:
Last Name:PEACH
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:BUILDING 73, MSC 06 3870
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-277-1074
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:BUILDING 73, MSC 06 3870
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-277-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0854133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered