Provider Demographics
NPI:1538521000
Name:PETRUCCELLI, MICHELE ELIZABETH
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ELIZABETH
Last Name:PETRUCCELLI
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 1:1246 MOHEGAN TRL
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7310
Mailing Address - Country:US
Mailing Address - Phone:440-220-0015
Mailing Address - Fax:
Practice Address - Street 1:36100 EUCLID AVENUE
Practice Address - Street 2:SUITE 240
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-953-6294
Practice Address - Fax:440-918-4687
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA18962-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily