Provider Demographics
NPI:1689178154
Name:PETRUCCI, SHAWN KRISTOPHER
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:KRISTOPHER
Last Name:PETRUCCI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 KINGS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-7675
Mailing Address - Country:US
Mailing Address - Phone:401-575-7122
Mailing Address - Fax:
Practice Address - Street 1:153 KINGS RIDGE RD
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-7675
Practice Address - Country:US
Practice Address - Phone:401-575-7122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer