Healthcare Provider Details

I. General information

NPI: 1508089673
Provider Name (Legal Business Name): NANCY JEAN PETRILAK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MEDICAL GROUP 77 NEALY AVE
LANGLEY AFB VA
23665-2023
US

IV. Provider business mailing address

104 CARNOUSTIE CT
YORKTOWN VA
23693-5517
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6973
  • Fax:
Mailing address:
  • Phone: 757-969-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9998
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: