Basic Information
| Provider Information | |||||||||
| NPI: | 1821584012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRUSEVICH | ||||||||
| FirstName: | VIKTORYIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 DRAKE DR | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553599479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522152742 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4201 DEAN LAKES BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553792850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524966700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2018 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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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 | 176B00000X | Y | Other Service Providers | Midwife |
No ID Information.