Provider Demographics
NPI:1861764060
Name:PETERS, AUDREY LYNN (RD)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:LYNN
Last Name:PETERS
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 1:5230 E STOP 11 RD
Mailing Address - Street 2:BUILDING A, SUITE 190
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-6398
Mailing Address - Country:US
Mailing Address - Phone:317-851-3695
Mailing Address - Fax:
Practice Address - Street 1:5230 E STOP 11 RD
Practice Address - Street 2:BUILDING A, SUITE 190
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6398
Practice Address - Country:US
Practice Address - Phone:317-851-3695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1042112133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered