Provider Demographics
NPI:1316052780
Name:PETERSON, LACIE MARIE (RD, CD, CDE)
Entity type:Individual
Prefix:MRS
First Name:LACIE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD, CD, CDE
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:MARIE
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD, CDE
Mailing Address - Street 1:2016 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1711
Mailing Address - Country:US
Mailing Address - Phone:801-699-5753
Mailing Address - Fax:801-585-5906
Practice Address - Street 1:615 ARAPEEN DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1267
Practice Address - Country:US
Practice Address - Phone:801-587-3961
Practice Address - Fax:801-585-5906
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6120423-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered