Provider Demographics
NPI:1922169200
Name:TIGUE-PETROSKI, LYNNITA M (DC)
Entity Type:Individual
Prefix:DR
First Name:LYNNITA
Middle Name:M
Last Name:TIGUE-PETROSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LYNNITA
Other - Middle Name:M
Other - Last Name:TIGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:98 FOREST DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LORDS VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-6140
Mailing Address - Country:US
Mailing Address - Phone:570-775-6205
Mailing Address - Fax:570-775-6205
Practice Address - Street 1:98 FOREST DR
Practice Address - Street 2:SUITE 2
Practice Address - City:LORDS VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-6140
Practice Address - Country:US
Practice Address - Phone:570-775-6205
Practice Address - Fax:570-775-6205
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008740111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012312930001Medicaid
PA818148OtherFIRST PRIORITY
PA1640258OtherBLUE SHIELD
PA056426TEXOtherMEDICARE PTAN
PA201331634OtherTAX ID
PA1640258OtherBLUE SHIELD
PA201331634OtherTAX ID