Provider Demographics
NPI:1831788355
Name:PETRY, SUSAN LYNNE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNNE
Last Name:PETRY
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 1:2451 CHANDALAR DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3510
Mailing Address - Country:US
Mailing Address - Phone:907-962-4322
Mailing Address - Fax:
Practice Address - Street 1:2451 CHANDALAR DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3510
Practice Address - Country:US
Practice Address - Phone:907-952-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12409163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse