Provider Demographics
NPI:1265741441
Name:PETRAKIS, THERESA MAUREEN
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MAUREEN
Last Name:PETRAKIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CORBETT RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-2055
Mailing Address - Country:US
Mailing Address - Phone:845-457-4810
Mailing Address - Fax:
Practice Address - Street 1:220 CORBETT RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-2055
Practice Address - Country:US
Practice Address - Phone:845-457-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY418165163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health