Provider Demographics
NPI:1336683697
Name:PETRONI, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:PETRONI
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 1:1222 S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-4911
Mailing Address - Country:US
Mailing Address - Phone:815-325-6512
Mailing Address - Fax:
Practice Address - Street 1:3130 PEORIA ST
Practice Address - Street 2:
Practice Address - City:STEGER
Practice Address - State:IL
Practice Address - Zip Code:60475-1037
Practice Address - Country:US
Practice Address - Phone:815-325-6512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041206872163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health