Provider Demographics
NPI:1790778702
Name:PETRACCI, DOROTHY L (CRNA)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:L
Last Name:PETRACCI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROUTE 73 N
Mailing Address - Street 2:40 LAKE CENTER DRIVE SUITE 201B
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3425
Mailing Address - Country:US
Mailing Address - Phone:856-355-0312
Mailing Address - Fax:856-355-0353
Practice Address - Street 1:401 ROUTE 73 N
Practice Address - Street 2:40 LAKE CENTER DRIVE SUITE 201B
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3425
Practice Address - Country:US
Practice Address - Phone:856-355-0312
Practice Address - Fax:856-355-0353
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNR40342367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ005516Medicare ID - Type Unspecified