Healthcare Provider Details

I. General information

NPI: 1295983146
Provider Name (Legal Business Name): KRISTEN ERNST PETTERSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 WALNUT ST
MONTCLAIR NJ
07042-2972
US

IV. Provider business mailing address

PO BOX 43463
UPPER MONTCLAIR NJ
07043-0463
US

V. Phone/Fax

Practice location:
  • Phone: 973-224-7644
  • Fax: 973-695-2003
Mailing address:
  • Phone: 973-224-7644
  • Fax: 973-695-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number631196
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number631196
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: