Basic Information
| Provider Information | |||||||||
| NPI: | 1033483748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETYAK | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | ENGSTROM | ||||||||
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| Credential: | CPNP-PC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ENGSTROM | ||||||||
| OtherFirstName: | CHRISTY | ||||||||
| OtherMiddleName: | JANELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 37215 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024765000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 MICHIGAN AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024765000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2012 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN1008781 | DC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.