Provider Demographics
NPI:1275254203
Name:PETRALLI, GENITA (AMNA)
Entity Type:Individual
Prefix:MS
First Name:GENITA
Middle Name:
Last Name:PETRALLI
Suffix:
Gender:F
Credentials:AMNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 N FM 620 RD APT 114
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-3513
Mailing Address - Country:US
Mailing Address - Phone:323-504-4639
Mailing Address - Fax:
Practice Address - Street 1:896 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4304
Practice Address - Country:US
Practice Address - Phone:512-879-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10116133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist