Provider Demographics
NPI:1467753079
Name:PETRILLO, KIM MARIE (REG PROF NURSE)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:REG PROF NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1247
Mailing Address - Country:US
Mailing Address - Phone:607-274-6363
Mailing Address - Fax:
Practice Address - Street 1:55 BROWN RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1247
Practice Address - Country:US
Practice Address - Phone:607-274-6363
Practice Address - Fax:607-274-6684
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY513163-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse