Provider Demographics
NPI:1124779699
Name:PETRYSZYN, KAITLYN RENEE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:RENEE
Last Name:PETRYSZYN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-3628
Mailing Address - Country:US
Mailing Address - Phone:607-771-0343
Mailing Address - Fax:
Practice Address - Street 1:2001D PARKFIELD CT # D
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3294
Practice Address - Country:US
Practice Address - Phone:607-222-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003513A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer