Provider Demographics
NPI:1932968096
Name:PETRACCA, ALICIA ANN
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:PETRACCA
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:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-0360
Mailing Address - Country:US
Mailing Address - Phone:516-500-1790
Mailing Address - Fax:
Practice Address - Street 1:1802 PETRACCA PL
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-6000
Practice Address - Country:US
Practice Address - Phone:516-500-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011762133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered