Provider Demographics
NPI:1649876459
Name:PETERSON, ALEXANDRIA NICOLE (RDN)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1784
Mailing Address - Country:US
Mailing Address - Phone:208-610-7610
Mailing Address - Fax:
Practice Address - Street 1:407 S FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1784
Practice Address - Country:US
Practice Address - Phone:208-610-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
IDD-1212133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered