Provider Demographics
NPI:1588430862
Name:PETRUSEK, MARIAH LEE (RDN)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LEE
Last Name:PETRUSEK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1328
Mailing Address - Country:US
Mailing Address - Phone:716-348-0057
Mailing Address - Fax:
Practice Address - Street 1:4330 MAPLE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14226-1064
Practice Address - Country:US
Practice Address - Phone:716-348-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011535-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered