Healthcare Provider Details

I. General information

NPI: 1912341470
Provider Name (Legal Business Name): MISTY C PETRAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 ASTOR ST
WELLFORD SC
29385
US

IV. Provider business mailing address

102 ASTOR ST
WELLFORD SC
29385-9622
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-5338
  • Fax:
Mailing address:
  • Phone: 864-439-5338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number106862
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number106862
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number106862
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21997
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: