Provider Demographics
NPI:1275953440
Name:PETRO, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PETRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4109
Mailing Address - Country:US
Mailing Address - Phone:440-255-4444
Mailing Address - Fax:
Practice Address - Street 1:6451 CENTER ST
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4109
Practice Address - Country:US
Practice Address - Phone:440-255-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 1551168163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool