Provider Demographics
NPI:1922048073
Name:PETRUZZI, MARY (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PETRUZZI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 SHERMAN HILL RD APT C10
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-3641
Mailing Address - Country:US
Mailing Address - Phone:203-605-0804
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:203-605-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333230-1363LF0000X
CT002938363LF0000X
MARN2269965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500002246Medicare PIN
CT500002246Medicare UPIN