Provider Demographics
NPI:1225205446
Name:PETITO, JENNIFER (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:PETITO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 PAUL CT
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4381
Mailing Address - Country:US
Mailing Address - Phone:631-696-7997
Mailing Address - Fax:631-696-7997
Practice Address - Street 1:59 WINNECOMAC CIR
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-4608
Practice Address - Country:US
Practice Address - Phone:631-269-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566776-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02841270OtherMEDICAID PROVIDER NUMBER