Provider Demographics
NPI:1144533837
Name:PETROSKY, KATHRYN BERNARD (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BERNARD
Last Name:PETROSKY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1994 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1305
Mailing Address - Country:US
Mailing Address - Phone:301-651-0493
Mailing Address - Fax:
Practice Address - Street 1:1225 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2350
Practice Address - Country:US
Practice Address - Phone:814-643-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004364133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102497058 0001Medicaid