Healthcare Provider Details

I. General information

NPI: 1942785290
Provider Name (Legal Business Name): NICOLETTE PETRUSIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 BABCOCK BLVD FL 2
PITTSBURGH PA
15237-5815
US

IV. Provider business mailing address

807 S BRADDOCK AVE APT 2
PITTSBURGH PA
15221-3419
US

V. Phone/Fax

Practice location:
  • Phone: 412-748-5589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN640755
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: