Provider Demographics
NPI:1043431786
Name:PETRUCCI, ELAINE MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MARIE
Last Name:PETRUCCI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 ANGUS CT
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2002
Mailing Address - Country:US
Mailing Address - Phone:410-451-5932
Mailing Address - Fax:410-222-6522
Practice Address - Street 1:6 RIGGS AVE
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3814
Practice Address - Country:US
Practice Address - Phone:410-222-6577
Practice Address - Fax:410-222-6522
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP34135164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse