Provider Demographics
NPI:1023097037
Name:PETRIK, MOLLY E (RD LMNT CDE)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:E
Last Name:PETRIK
Suffix:
Gender:F
Credentials:RD LMNT CDE
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LMNT,CDE
Mailing Address - Street 1:1949 NW 44TH STREET
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68528
Mailing Address - Country:US
Mailing Address - Phone:319-621-6107
Mailing Address - Fax:
Practice Address - Street 1:2246 O ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-1121
Practice Address - Country:US
Practice Address - Phone:402-413-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01544133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08944Medicare UPIN
IAI11334Medicare ID - Type Unspecified