Healthcare Provider Details

I. General information

NPI: 1649812405
Provider Name (Legal Business Name): NICOLE E PETGRAVE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 MENTOR HILLS DR
MENTOR OH
44060-7861
US

IV. Provider business mailing address

333 N SUMMIT ST FL 7
TOLEDO OH
43604-1531
US

V. Phone/Fax

Practice location:
  • Phone: 800-427-1902
  • Fax: 419-531-2664
Mailing address:
  • Phone: 419-252-6018
  • Fax: 800-564-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.024887
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.024887
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: