Provider Demographics
NPI:1811328933
Name:PETERSON, ASHLEY (RDN)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E SECOND ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-4458
Mailing Address - Country:US
Mailing Address - Phone:228-860-7530
Mailing Address - Fax:
Practice Address - Street 1:212 E SECOND ST
Practice Address - Street 2:SUITE A
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-4458
Practice Address - Country:US
Practice Address - Phone:228-860-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-30
Last Update Date:2013-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1587133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered