Provider Demographics
NPI:1063519478
Name:KEARNS, PEGGY WOLF (RD)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:WOLF
Last Name:KEARNS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 152ND ST W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4652
Mailing Address - Country:US
Mailing Address - Phone:612-725-2121
Mailing Address - Fax:612-725-2141
Practice Address - Street 1:1 VETERANS DR # 17
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-725-2121
Practice Address - Fax:612-725-2141
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R526238133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered