Provider Demographics
NPI:1922101286
Name:PETRIK, MARY ELIZABETH (RD L D)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:PETRIK
Suffix:
Gender:F
Credentials:RD L D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 W 160TH ST S
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:KS
Mailing Address - Zip Code:67022-8601
Mailing Address - Country:US
Mailing Address - Phone:620-845-2984
Mailing Address - Fax:620-845-2986
Practice Address - Street 1:601 S OSAGE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:KS
Practice Address - Zip Code:67022-1654
Practice Address - Country:US
Practice Address - Phone:620-845-6492
Practice Address - Fax:620-845-6475
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS280133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered