Provider Demographics
NPI:1588846166
Name:PETRUSICK, LINDA JOYCE (NP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:JOYCE
Last Name:PETRUSICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 JESSAMINE STREET PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442
Mailing Address - Country:US
Mailing Address - Phone:843-546-8686
Mailing Address - Fax:843-546-1353
Practice Address - Street 1:57 JESSAMINE STREET
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29442
Practice Address - Country:US
Practice Address - Phone:843-546-8686
Practice Address - Fax:843-546-1353
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP2239363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics