Provider Demographics
NPI:1477134252
Name:HERNANDEZ PETRULO, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:HERNANDEZ PETRULO
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 1:2107 CEDAR GROVE TRL APT 114
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1612
Mailing Address - Country:US
Mailing Address - Phone:952-210-6330
Mailing Address - Fax:
Practice Address - Street 1:2107 CEDAR GROVE TRL APT 114
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1612
Practice Address - Country:US
Practice Address - Phone:952-210-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN008832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer