Provider Demographics
NPI:1902359078
Name:PETEFISH, BROOKE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PETEFISH
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8065 CIMARRON MEADOWS WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-5054
Mailing Address - Country:US
Mailing Address - Phone:623-229-2663
Mailing Address - Fax:
Practice Address - Street 1:8065 CIMARRON MEADOWS WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-5054
Practice Address - Country:US
Practice Address - Phone:623-229-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05064092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer