Provider Demographics
NPI:1255393716
Name:PETZCHEN, MARCELLA M (NP)
Entity type:Individual
Prefix:MS
First Name:MARCELLA
Middle Name:M
Last Name:PETZCHEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 RUTGER AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-977-4440
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-977-6100
Practice Address - Fax:314-977-6137
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO051062163W00000X, 363LA2200X, 363LP2300X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health