Provider Demographics
NPI:1508563479
Name:REYES, PETAGAYE LATOYA (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:PETAGAYE
Middle Name:LATOYA
Last Name:REYES
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 THOURON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2309
Mailing Address - Country:US
Mailing Address - Phone:267-257-5877
Mailing Address - Fax:
Practice Address - Street 1:8501 THOURON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-2309
Practice Address - Country:US
Practice Address - Phone:267-257-5877
Practice Address - Fax:215-539-2470
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN553029363LP0808X
PASP027047363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health