Provider Demographics
NPI:1437146339
Name:PETRIN, JUDITH (APRN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:PETRIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9220
Mailing Address - Fax:239-343-9231
Practice Address - Street 1:12600 CREEKSIDE LN
Practice Address - Street 2:SUITE 7
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3353
Practice Address - Country:US
Practice Address - Phone:239-343-9220
Practice Address - Fax:239-343-9231
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1196972364SG0600X
FLARNP1196972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302429600Medicaid
FL500029866Medicare PIN
FLE1082YMedicare PIN