Individual
KELLY PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD
Contact information
Practice address
841 MCKAY ST, CHUBBUCK, ID 83202-4961
(208) 705-5553
Mailing address
3724 JEFFERSON ST STE 104, AUSTIN, TX 78731-6204
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
—
—
Other
Enumeration date
10/09/2023
Last updated
10/09/2023
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