Provider Demographics
NPI:1285078063
Name:PETUSEVSKY, WENDY SUSAN (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:SUSAN
Last Name:PETUSEVSKY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 N FEDERAL HWY
Mailing Address - Street 2:NUTRITION SERVICES DEPARTMENT
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4603
Mailing Address - Country:US
Mailing Address - Phone:954-771-8000
Mailing Address - Fax:954-776-3266
Practice Address - Street 1:4725 N FEDERAL HWY
Practice Address - Street 2:NUTRITION SERVICES DEPARTMENT
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-771-8000
Practice Address - Fax:954-776-3266
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 4082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered