Healthcare Provider Details

I. General information

NPI: 1174874846
Provider Name (Legal Business Name): AMY M. PETRILLO C.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 W MAIN ST STE. A
LOUISVILLE OH
44641-1114
US

IV. Provider business mailing address

1302 W MAIN ST STE. A
LOUISVILLE OH
44641-1114
US

V. Phone/Fax

Practice location:
  • Phone: 330-875-5544
  • Fax: 330-875-8150
Mailing address:
  • Phone: 330-875-5544
  • Fax: 330-875-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA 13890-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: