Healthcare Provider Details

I. General information

NPI: 1285078063
Provider Name (Legal Business Name): WENDY SUSAN PETUSEVSKY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 N FEDERAL HWY NUTRITION SERVICES DEPARTMENT
FT LAUDERDALE FL
33308-4603
US

IV. Provider business mailing address

4725 N FEDERAL HWY NUTRITION SERVICES DEPARTMENT
FT LAUDERDALE FL
33308-4603
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-8000
  • Fax: 954-776-3266
Mailing address:
  • Phone: 954-771-8000
  • Fax: 954-776-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 4082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: