Provider Demographics
NPI:1649812405
Name:PETGRAVE, NICOLE E (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:PETGRAVE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:419-252-6018
Mailing Address - Fax:800-564-5952
Practice Address - Street 1:8200 MENTOR HILLS DR
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7861
Practice Address - Country:US
Practice Address - Phone:800-427-1902
Practice Address - Fax:419-531-2664
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024887363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health