Provider Demographics
NPI:1023565355
Name:PETERSON, KRISTINE MIKA (RD)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:MIKA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:TAMAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:1550 N 115TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8401
Practice Address - Country:US
Practice Address - Phone:206-520-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1033963133V00000X
WADI60720921133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1033963OtherCOMMITTEE ON DIETETIC REGISTRATION ID NUMBER
WA1023565355Medicaid