Provider Demographics
NPI:1043862105
Name:PETROUS, MIRENA (RN)
Entity type:Individual
Prefix:
First Name:MIRENA
Middle Name:
Last Name:PETROUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:IRENA
Other - Middle Name:
Other - Last Name:PETROUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:4201 SUZANNE DR
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-4336
Mailing Address - Country:US
Mailing Address - Phone:917-494-7477
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:408-259-2273
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95159089163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health