Provider Demographics
NPI:1538826078
Name:PETERSON, LAUREN NICOLE LOIS (RD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE LOIS
Last Name:PETERSON
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 1:2601 FLORAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-4113
Mailing Address - Country:US
Mailing Address - Phone:406-560-7786
Mailing Address - Fax:
Practice Address - Street 1:901 BYERS DR # 1072
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-3323
Practice Address - Country:US
Practice Address - Phone:508-907-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-60066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered