Healthcare Provider Details

I. General information

NPI: 1407807225
Provider Name (Legal Business Name): MARY E SIKORA-PETERSEN MSE, RD, CD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 TOWNLINE RD
MINOCQUA WI
54548-1390
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-1000
  • Fax:
Mailing address:
  • Phone: 715-387-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1450
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: