Basic Information
| Provider Information | |||||||||
| NPI: | 1003580002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTERBORG | ||||||||
| FirstName: | WHITNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 172 MEADOW CIR | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843215095 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 517 W 100 N STE 110 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843329826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556075 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2021 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86118135 | UT | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.