Provider Demographics
NPI:1124675574
Name:PETRISOR, JANELLE R
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:R
Last Name:PETRISOR
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 1:200 W DOUGLAS AVE STE 1040
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3017
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:
Practice Address - Street 1:3460 N RIDGE RD STE 80
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1223
Practice Address - Country:US
Practice Address - Phone:316-202-0340
Practice Address - Fax:316-202-0341
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1106278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist