Provider Demographics
NPI:1720229685
Name:PETITO, EMILY COLLEEN (CRNP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:COLLEEN
Last Name:PETITO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:COLLEEN
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:3002 HUNTING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4950
Mailing Address - Country:US
Mailing Address - Phone:410-356-8016
Mailing Address - Fax:
Practice Address - Street 1:401 N BROADWAY ST
Practice Address - Street 2:SIDNEY KIMMEL COMPREHENSIVE CANCER CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0019
Practice Address - Country:US
Practice Address - Phone:410-955-8893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR163713363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD023692600Medicaid