Healthcare Provider Details

I. General information

NPI: 1336156629
Provider Name (Legal Business Name): DIANE M PETERSON RD,LD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

3685 WINDTREE DR
EAGAN MN
55123-1320
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-3948
  • Fax: 612-727-5997
Mailing address:
  • Phone: 651-456-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1965
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: