Provider Demographics
NPI:1952908824
Name:PETTRY, STACY LYNN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:PETTRY
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 1:242 BALD ROCK RD
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:VA
Mailing Address - Zip Code:24482-2825
Mailing Address - Country:US
Mailing Address - Phone:197-284-9969
Mailing Address - Fax:
Practice Address - Street 1:242 BALD ROCK RD
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:VA
Practice Address - Zip Code:24482-2825
Practice Address - Country:US
Practice Address - Phone:972-849-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA