Healthcare Provider Details

I. General information

NPI: 1760839070
Provider Name (Legal Business Name): DEANNA M PETSAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 MCCRACKEN RD
GARFIELD HEIGHTS OH
44125-2914
US

IV. Provider business mailing address

35157 POPLAR ST
NORTH RIDGEVILLE OH
44039-1549
US

V. Phone/Fax

Practice location:
  • Phone: 330-720-6388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCOA.19128-NS
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberCOA.19128-NS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: