Provider Demographics
NPI:1679906606
Name:LIP, PETRONELLA W (RN)
Entity type:Individual
Prefix:
First Name:PETRONELLA
Middle Name:W
Last Name:LIP
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W MATHEWS RD
Mailing Address - Street 2:
Mailing Address - City:FRENCH CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95231-9757
Mailing Address - Country:US
Mailing Address - Phone:209-468-4267
Mailing Address - Fax:
Practice Address - Street 1:535 W MATHEWS RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9757
Practice Address - Country:US
Practice Address - Phone:209-468-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN294328163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse