Provider Demographics
NPI:1558754325
Name:PETIK, WENDY (RN, MSN)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:
Last Name:PETIK
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:MRS
Other - First Name:WENDY
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CMR 414
Mailing Address - Street 2:BOX 2615
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09173
Mailing Address - Country:US
Mailing Address - Phone:804-731-2747
Mailing Address - Fax:
Practice Address - Street 1:CMR 414
Practice Address - Street 2:BOX 2615
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09173
Practice Address - Country:US
Practice Address - Phone:804-731-2747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001186324163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse