Provider Demographics
NPI:1073779096
Name:PETROS, ANN MARIE (PMHNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:PETROS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 820153
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282
Mailing Address - Country:US
Mailing Address - Phone:503-754-3050
Mailing Address - Fax:800-381-8993
Practice Address - Street 1:1616 SE BYBEE BLVD.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-793-8004
Practice Address - Fax:800-381-8993
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200743401RN163W00000X
OR200950105NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse