Healthcare Provider Details

I. General information

NPI: 1366458192
Provider Name (Legal Business Name): MERRILL DEPETRILLO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 HIGHWAY 515 S
JASPER GA
30143-4872
US

IV. Provider business mailing address

6010 RILEY RD
CUMMING GA
30028-5927
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-2441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN108911
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberRN108911
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: