Provider Demographics
NPI:1699126474
Name:PETRUZZI, LISA TAM (ATC, VATL)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:TAM
Last Name:PETRUZZI
Suffix:
Gender:F
Credentials:ATC, VATL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3104
Mailing Address - Country:US
Mailing Address - Phone:703-810-2327
Mailing Address - Fax:
Practice Address - Street 1:700 BENNETT ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3104
Practice Address - Country:US
Practice Address - Phone:703-810-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260000692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer