Provider Demographics
NPI:1508089673
Name:PETRILAK, NANCY JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JEAN
Last Name:PETRILAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CARNOUSTIE CT
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5517
Mailing Address - Country:US
Mailing Address - Phone:757-969-5368
Mailing Address - Fax:
Practice Address - Street 1:1ST MEDICAL GROUP
Practice Address - Street 2:77 NEALY AVE
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2023
Practice Address - Country:US
Practice Address - Phone:757-764-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist