Provider Demographics
NPI:1801361183
Name:PETERSON, EMMA (RD)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-329-5781
Mailing Address - Fax:406-327-3331
Practice Address - Street 1:900 N ORANGE ST STE 304
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2951
Practice Address - Country:US
Practice Address - Phone:406-329-5781
Practice Address - Fax:406-327-3331
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT69119133V00000X
MTMED-NUTR-LIC-69119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered