Provider Demographics
NPI:1730203613
Name:PETRO, KATHLEEN ANN (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:PETRO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3424
Mailing Address - Country:US
Mailing Address - Phone:307-335-7720
Mailing Address - Fax:307-335-7723
Practice Address - Street 1:535 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3424
Practice Address - Country:US
Practice Address - Phone:307-335-7720
Practice Address - Fax:307-335-7723
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15565.0169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
314168OtherBCBS
WY122992300Medicaid
P62296Medicare UPIN