Provider Demographics
NPI:1366529059
Name:PETERSON, HEATHER (RD, LMNT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:NE
Mailing Address - Zip Code:68876-9607
Mailing Address - Country:US
Mailing Address - Phone:308-647-6738
Mailing Address - Fax:
Practice Address - Street 1:2116 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4645
Practice Address - Country:US
Practice Address - Phone:308-398-6540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered