Basic Information
| Provider Information | |||||||||
| NPI: | 1578850558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETROCCIONE | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 LEROY ST | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136761799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | 3152616025 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 EAST MAIN ST | ||||||||
| Address2: | CANTON PEDIATRICS | ||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152615615 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 06/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 22570374 | NY | N | Nursing Service Providers | Registered Nurse | 163WS0200X | 22570374 | NY | N | Nursing Service Providers | Registered Nurse | School | 363LP0200X | 382969 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.