Provider Demographics
NPI:1821278458
Name:PETERSON, WENDY JO (RD)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:JO
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 LAKE APOPKA PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2813
Mailing Address - Country:US
Mailing Address - Phone:619-713-1575
Mailing Address - Fax:
Practice Address - Street 1:6330 LAKE APOPKA PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-2813
Practice Address - Country:US
Practice Address - Phone:619-713-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered