Healthcare Provider Details

I. General information

NPI: 1740219146
Provider Name (Legal Business Name): EVA PETKAC DONNELLY RD/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4689 FULTON DR NW
CANTON OH
44718-2379
US

IV. Provider business mailing address

4685 FULTON DR NW
CANTON OH
44718-2379
US

V. Phone/Fax

Practice location:
  • Phone: 330-649-9400
  • Fax: 330-649-8059
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number21
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: