Healthcare Provider Details

I. General information

NPI: 1356648695
Provider Name (Legal Business Name): KINDRA SUE PETERSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 E DESERT COVE AVE
SCOTTSDALE AZ
85260-6746
US

IV. Provider business mailing address

PO BOX 6423
CHANDLER AZ
85246-6423
US

V. Phone/Fax

Practice location:
  • Phone: 480-314-6670
  • Fax: 480-257-1997
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number853386
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: