Provider Demographics
NPI:1174874846
Name:PETRILLO, AMY M (CNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 W MAIN ST
Mailing Address - Street 2:STE. A
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-1114
Mailing Address - Country:US
Mailing Address - Phone:330-875-5544
Mailing Address - Fax:330-875-8150
Practice Address - Street 1:1302 W MAIN ST
Practice Address - Street 2:STE. A
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1114
Practice Address - Country:US
Practice Address - Phone:330-875-5544
Practice Address - Fax:330-875-8150
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 13890-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073609Medicaid
OHH160620Medicare UPIN