Provider Demographics
NPI:1821584012
Name:PETRUSEVICH, VIKTORYIA (CNM)
Entity Type:Individual
Prefix:
First Name:VIKTORYIA
Middle Name:
Last Name:PETRUSEVICH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9479
Mailing Address - Country:US
Mailing Address - Phone:952-215-2742
Mailing Address - Fax:
Practice Address - Street 1:4201 DEAN LAKES BLVD STE 120
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2850
Practice Address - Country:US
Practice Address - Phone:952-496-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife