Provider Demographics
NPI:1992251631
Name:PETOELLO, VANESSA LYNN (ANP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:LYNN
Last Name:PETOELLO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N/ OCEAN AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-654-5004
Mailing Address - Fax:631-654-5048
Practice Address - Street 1:107 N/ OCEAN AVE
Practice Address - Street 2:SUITE G
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-654-5004
Practice Address - Fax:631-654-5048
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307851-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health