Provider Demographics
NPI:1871125930
Name:PETROFF, MIRYAH
Entity type:Individual
Prefix:
First Name:MIRYAH
Middle Name:
Last Name:PETROFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 S 259TH PL
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-9761
Mailing Address - Country:US
Mailing Address - Phone:206-227-8906
Mailing Address - Fax:
Practice Address - Street 1:3415 S 259TH PL
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-9761
Practice Address - Country:US
Practice Address - Phone:206-227-8906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00173873163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse