Provider Demographics
NPI:1871840645
Name:PETRONE, MARISA (PT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:PETRONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 HAMBURG TPKE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-8480
Mailing Address - Country:US
Mailing Address - Phone:973-706-7620
Mailing Address - Fax:973-706-7619
Practice Address - Street 1:450 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-8480
Practice Address - Country:US
Practice Address - Phone:973-706-7620
Practice Address - Fax:973-706-7619
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01450400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist