Provider Demographics
NPI:1962697664
Name:PETREDIS, MISTY ANN (LPN)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:ANN
Last Name:PETREDIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7063 W HAMILTON PL UNIT 1315
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3083
Mailing Address - Country:US
Mailing Address - Phone:513-678-7991
Mailing Address - Fax:
Practice Address - Street 1:6383 REDMONT CT
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-8665
Practice Address - Country:US
Practice Address - Phone:513-678-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2025-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN126935164W00000X
OH397234163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2763764Medicaid