Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207L00000X | Anesthesiologist | 0101233589 | VA |
N | 208000000X | Pediatrician | 0101233589 | VA |
Y | 2080P0204X | Pediatric Emergency Doctor | 0101233589 | VA |
NPI | 1083661151 |
---|---|
Provider Name | Kelli A Petronis |
First Address | Baltimore, MD 21279-0137 |
Second Address | Norfolk, VA 23507-1910 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2006 |
Last Update Date | 18/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
006739105 | (05) | VA |
1010661080001 | (05) | PA |
403654900 | (05) | MD |
89066C4 | (05) | NC |
H84799 | (02) |