Provider Demographics
NPI:1184253262
Name:KERRI PETITPAIN MEDICAL
Entity type:Organization
Organization Name:KERRI PETITPAIN MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PETITPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP-C
Authorized Official - Phone:631-905-6890
Mailing Address - Street 1:18 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2624
Mailing Address - Country:US
Mailing Address - Phone:631-905-6890
Mailing Address - Fax:888-920-2296
Practice Address - Street 1:18 SCOTT LN
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2624
Practice Address - Country:US
Practice Address - Phone:631-905-6890
Practice Address - Fax:888-920-2296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03410419Medicaid