Provider Demographics
NPI:1316293822
Name:PETKE, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:PETKE
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 1:410 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:614-293-8305
Mailing Address - Fax:614-293-3124
Practice Address - Street 1:376 W 10TH AVE
Practice Address - Street 2:791 PRIOR HALL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:614-293-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN341177163W00000X
OH13711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse