Healthcare Provider Details

I. General information

NPI: 1902153901
Provider Name (Legal Business Name): LAUREN PETRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N UNIVERSITY BLVD SUITE 3005
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

17254 140TH AVE
RENTON WA
98058
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2167
  • Fax:
Mailing address:
  • Phone: 425-226-7614
  • Fax: 509-241-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004087A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28203630A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60260385
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: