Provider Demographics
NPI:1528328275
Name:PETERSON, AMANDA (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:25 COURTENAY DRIVE, SUITE 7100A MSC 290
Mailing Address - Street 2:MEDICAL UNIVERSITY OF SOUTH CAROLINA
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:843-876-4867
Mailing Address - Fax:484-334-7026
Practice Address - Street 1:25 COURTENAY DRIVE, SUITE 7100A MSC 290
Practice Address - Street 2:MEDICAL UNIVERSITY OF SOUTH CAROLINA
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-876-4867
Practice Address - Fax:610-568-3139
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1219133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered