Provider Demographics
NPI:1841321866
Name:PETYAK-RYAN, JULIE ANN (LAC)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:PETYAK-RYAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CALLE TECATE STE 211
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5287
Mailing Address - Country:US
Mailing Address - Phone:805-738-7210
Mailing Address - Fax:805-738-7210
Practice Address - Street 1:4000 CALLE TECATE STE 211
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5287
Practice Address - Country:US
Practice Address - Phone:805-738-7210
Practice Address - Fax:805-738-7210
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 7834171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-0136192OtherEIN