Provider Demographics
NPI:1578850558
Name:PETROCCIONE, ANN ELIZABETH (PNP)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:ELIZABETH
Last Name:PETROCCIONE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1799
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:80 EAST MAIN ST
Practice Address - Street 2:CANTON PEDIATRICS
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-261-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22570374163W00000X, 163WS0200X
NY382969363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No163WS0200XNursing Service ProvidersRegistered NurseSchool