MEDICARE: MICHELLE PETRIE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	00028224	OH

General Provider Information

NPI Number	:	1336704972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE PETRIE

Provider Business Mailing Address
First Line	:	2055 ALEXANDRIA WAY
Second Line	:
City	:	MACEDONIA
State	:	OH
Zip	:	44056-1998
Country	:	US
Telephone Number	:	330-468-3312
Fax Number	:

Provider Business Practice Location Address
First Line	:	2055 ALEXANDRIA WAY
Second Line	:
City	:	MACEDONIA
State	:	OH
Zip	:	44056-1998
Country	:	US
Telephone Number	:	330-468-3312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2019
Last Update Date	:	05/09/2019

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Directions to “ MICHELLE PETRIE ” Practice Location

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