Basic Information
| Provider Information | |||||||||
| NPI: | 1669661559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 218 | ||||||||
| Address2: | 2600 65TH AVENUE | ||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540203024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152942111 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 65TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540203024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152942111 | ||||||||
| FaxNumber: | 7152945758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 898228 | WI | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 40815 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 898228 | 01 | WI | CERTIFICATE | OTHER |