Provider Demographics
NPI:1295983146
Name:PETTERSON, KRISTEN ERNST (RD)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:ERNST
Last Name:PETTERSON
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:PO BOX 43463
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-0463
Mailing Address - Country:US
Mailing Address - Phone:973-224-7644
Mailing Address - Fax:973-695-2003
Practice Address - Street 1:226 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2972
Practice Address - Country:US
Practice Address - Phone:973-224-7644
Practice Address - Fax:973-695-2003
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
631196133V00000X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered