Provider Demographics
NPI:1235374026
Name:PETRIE, COLLEN IRENE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:COLLEN
Middle Name:IRENE
Last Name:PETRIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:COLLEEN
Other - Middle Name:IRENE
Other - Last Name:YAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:P.O. BOX 599
Mailing Address - Street 2:114 SECOND AVE
Mailing Address - City:CAROGA LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12032
Mailing Address - Country:US
Mailing Address - Phone:518-630-7191
Mailing Address - Fax:
Practice Address - Street 1:114 2ND AVE
Practice Address - Street 2:1ST HOUSE ON RIGHT
Practice Address - City:CAROGA LAKE
Practice Address - State:NY
Practice Address - Zip Code:12032
Practice Address - Country:US
Practice Address - Phone:518-630-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150371-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse