Kelly Petersen, RD

Primary specialty

Registered DietitianTaxonomy code 133V00000X

Practice address

841 McKay St
Chubbuck, ID 83202-4961

Phone

(208) 705-5553

NPI assigned

Oct 9, 2023

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Specialty

Registered Dietitian Or Nutrition Professional

Education

Other, 2012

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Nourish, Inc.Group PAC ID 1557724937, 288 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Nourish, Inc.

  • Registered Dietitian
  • Austin, TX
  • NPI 1558097824

  Dietitian, Registered

  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1696809600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1696809600000",
    "number": "1407637101",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3724 JEFFERSON ST STE 104",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "787316204"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "841 MCKAY ST",
            "city": "CHUBBUCK",
            "state": "ID",
            "postal_code": "832024961",
            "telephone_number": "208-705-5553"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "KELLY",
        "credential": "RD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-10-09",
        "last_updated": "2023-10-09",
        "certification_date": "2023-10-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Holly Noelle Pace, OTR/L
• Savanah Shae Packard, LPC
• Timothy Lee Page, D.C.
• Mason Palmer
• Alan David Pannier, PHARMACY INTERN
• Wiley D Petersen, PA-C
• Maryn Peterson, PARAPROFESSIONAL
• Robin Lee Phillips
• Phoenix Management LLC
• Pinnacle Range of Motion, LLC

• Registered Dietitian in Chubbuck, ID
• Providers in Chubbuck, ID by specialty
• Registered Dietitian in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 9, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.