Provider Demographics
NPI:1053948943
Name:PETERSEN, NICOLE MARIE (RD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PETERSEN
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 1:118 GLENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-5862
Mailing Address - Country:US
Mailing Address - Phone:925-917-9724
Mailing Address - Fax:
Practice Address - Street 1:118 GLENVIEW DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-5862
Practice Address - Country:US
Practice Address - Phone:925-917-9724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered