Provider Demographics
NPI:1881007912
Name:PETROFF, COURTNEY LEIGH (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:LEIGH
Last Name:PETROFF
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEIGH
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN BSN
Mailing Address - Street 1:7472 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-2220
Mailing Address - Country:US
Mailing Address - Phone:314-401-5257
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012008949163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse