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General NPI Number Information
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NPI Number | 1659881597
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Entity Type | Individual
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Provider Name | CRYSTAL LYNN PETERSEN RDN, LD
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Gender | Female
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Dates
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Enumeration Date | 10/05/2017
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Last Update Date | 10/05/2017
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Provider Practice Location Address
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Address Line | 201 E J AVE
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City | GRUNDY CENTER
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State | IA
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Zip | 50638-2028
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Country | US
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Telephone | 319-824-5421
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Fax |
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Provider Business Mailing Address
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Address Line | 1334 C AVE
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City | GLADBROOK
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State | IA
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Zip | 50635-9356
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Country | US
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Telephone | 319-239-4352
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 00703
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License Number State | IA
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