1164524575 NPI number — MRS. COLLEEN MALENA PETITTO RD, LDN, CDE

Table of content: MRS. COLLEEN MALENA PETITTO RD, LDN, CDE (NPI 1164524575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164524575 NPI number — MRS. COLLEEN MALENA PETITTO RD, LDN, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETITTO
Provider First Name:
COLLEEN
Provider Middle Name:
MALENA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALENA
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, LDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164524575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 ARENTZEN BLVD
Provider Second Line Business Mailing Address:
VISTA ONE PROFESSIONAL CENTER SUITE 105
Provider Business Mailing Address City Name:
CHARLEROI
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15022-1085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-489-0850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 ARENTZEN BLVD
Provider Second Line Business Practice Location Address:
VISTA ONE PROFESSIONAL CENTER SUITE 105
Provider Business Practice Location Address City Name:
CHARLEROI
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15022-1085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-489-0850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DN 001238 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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