MEDICARE: MRS. DEBRA PETITPAIN MS, LD, RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1013927953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBRA PETITPAIN MS, LD, RD

Provider Business Mailing Address
First Line	:	10 STRATFORD RD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-7246
Country	:	US
Telephone Number	:	843-876-4867
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 COURTENAY DR
Second Line	:	MSC 290, STE7100A
City	:	CHARLESTON
State	:	SC
Zip	:	29425-8905
Country	:	US
Telephone Number	:	843-876-4867
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2013

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