Provider Demographics
NPI:1013319433
Name:PETRILLO, SUSAN EILEEN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:EILEEN
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 WEATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3543
Mailing Address - Country:US
Mailing Address - Phone:302-367-4583
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:3D38
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-5628
Practice Address - Fax:302-733-3887
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELP-00001118363L00000X
PASP014891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner