Provider Demographics
NPI:1982059952
Name:PETALOSO INC
Entity Type:Organization
Organization Name:PETALOSO INC
Other - Org Name:PETALOSO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STABLES
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ANP
Authorized Official - Phone:907-978-7721
Mailing Address - Street 1:1867 AIRPORT WAY STE 110B
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4054
Mailing Address - Country:US
Mailing Address - Phone:907-978-7721
Mailing Address - Fax:907-452-6330
Practice Address - Street 1:1867 AIRPORT WAY STE 110B
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4054
Practice Address - Country:US
Practice Address - Phone:907-978-7721
Practice Address - Fax:907-452-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK420363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty