Provider Demographics
NPI:1649647785
Name:PETRELLA, GINA (ANP-C)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WHALEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-4421
Mailing Address - Country:US
Mailing Address - Phone:631-422-0797
Mailing Address - Fax:
Practice Address - Street 1:45 WHALEN ST
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-4421
Practice Address - Country:US
Practice Address - Phone:631-422-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307381-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health