Provider Demographics
NPI:1780121152
Name:PETERSON, KATIE MARIE (RD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
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 1:1161 CHESTNUT COVE RD
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-7246
Mailing Address - Country:US
Mailing Address - Phone:260-494-9858
Mailing Address - Fax:
Practice Address - Street 1:1161 CHESTNUT COVE RD
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-7246
Practice Address - Country:US
Practice Address - Phone:260-494-9858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005088133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered