Provider Demographics
NPI:1861087553
Name:PETRENKO, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PETRENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 HOPMEADOW ST STE 115
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-5405
Mailing Address - Country:US
Mailing Address - Phone:860-261-2591
Mailing Address - Fax:
Practice Address - Street 1:96 COUNTY RD
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1245
Practice Address - Country:US
Practice Address - Phone:860-261-2591
Practice Address - Fax:860-217-0815
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2023-05-30
Deactivation Date:2021-03-05
Deactivation Code:
Reactivation Date:2023-05-26
Provider Licenses
StateLicense IDTaxonomies
CTHCA.0001577253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care