Provider Demographics
NPI:1902540594
Name:PETRILLO, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PETRILLO
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 1:245 VICARAGE CT
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-7866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 VICARAGE CT
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-7866
Practice Address - Country:US
Practice Address - Phone:770-365-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN237354163WN0800X, 163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WX0200XNursing Service ProvidersRegistered NurseOncologyGroup - Multi-Specialty
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience