Provider Demographics
NPI:1285331769
Name:PETROSEVICH, LISA ANN
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:PETROSEVICH
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 1:95 WEST ST UNIT 1304
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1857
Mailing Address - Country:US
Mailing Address - Phone:781-619-6074
Mailing Address - Fax:
Practice Address - Street 1:95 WEST ST UNIT 1304
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1857
Practice Address - Country:US
Practice Address - Phone:781-619-6074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider