Basic Information
| Provider Information | |||||||||
| NPI: | 1174874846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRILLO | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | C.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 W MAIN ST | ||||||||
| Address2: | STE. A | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446411114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 W MAIN ST | ||||||||
| Address2: | STE. A | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446411114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2012 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA 13890-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0073609 | 05 | OH | MEDICAID |