Healthcare Provider Details

I. General information

NPI: 1558646182
Provider Name (Legal Business Name): KATHERINE A. PETRILLO R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 MT HOPE RD
MIDDLETOWN NY
10940-7135
US

IV. Provider business mailing address

8 CARROLL DR
WARWICK NY
10990-1823
US

V. Phone/Fax

Practice location:
  • Phone: 845-344-2292
  • Fax:
Mailing address:
  • Phone: 845-986-9766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number335941-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: