Provider Demographics
NPI:1629278114
Name:PETRUS, WENDY NICOLE (MS)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:NICOLE
Last Name:PETRUS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13335 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:LA
Mailing Address - Zip Code:70437-6171
Mailing Address - Country:US
Mailing Address - Phone:985-502-1319
Mailing Address - Fax:
Practice Address - Street 1:13335 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:LA
Practice Address - Zip Code:70437-6171
Practice Address - Country:US
Practice Address - Phone:985-502-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5768235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist