Healthcare Provider Details

I. General information

NPI: 1558505560
Provider Name (Legal Business Name): STEPHANIE PETREAS RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 TELEGRAPH AVE STE 130
BERKELEY CA
94705-1159
US

IV. Provider business mailing address

2850 TELEGRAPH AVE STE 130
BERKELEY CA
94705-1159
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-8110
  • Fax: 510-843-0804
Mailing address:
  • Phone: 510-204-8110
  • Fax: 510-843-0804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number697900
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: