Provider Demographics
NPI:1568274645
Name:PETRELLA-MCMULLEN, TRISTA A (LPN, LMBT)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:A
Last Name:PETRELLA-MCMULLEN
Suffix:
Gender:F
Credentials:LPN, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 STEEPLE CHASE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6939
Mailing Address - Country:US
Mailing Address - Phone:910-381-0265
Mailing Address - Fax:
Practice Address - Street 1:3022 STEEPLE CHASE CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6939
Practice Address - Country:US
Practice Address - Phone:910-381-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22319225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist