Provider Demographics
NPI:1679006431
Name:PETRO, ELIZABETH ANN (RN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:PETRO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 FAIRCOURT DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7802
Mailing Address - Country:US
Mailing Address - Phone:813-662-4211
Mailing Address - Fax:
Practice Address - Street 1:4323 FAIRCOURT DR
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-7802
Practice Address - Country:US
Practice Address - Phone:813-662-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9163333163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9163333OtherREGISTERED