Provider Demographics
NPI:1144701970
Name:PETTYJOHN-ROBIN, LAUREN ANNICK
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ANNICK
Last Name:PETTYJOHN-ROBIN
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 1:6404 ORLY LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-2980
Mailing Address - Country:US
Mailing Address - Phone:301-875-7154
Mailing Address - Fax:
Practice Address - Street 1:6404 ORLY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-2980
Practice Address - Country:US
Practice Address - Phone:301-875-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
NY0039622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty