Provider Demographics
NPI:1710007802
Name:PETERSON, LOIS (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LORING PKWY
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-3618
Mailing Address - Country:US
Mailing Address - Phone:401-475-1788
Mailing Address - Fax:
Practice Address - Street 1:153 SUMMER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4011
Practice Address - Country:US
Practice Address - Phone:401-276-4300
Practice Address - Fax:401-331-3285
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered