Provider Demographics
NPI:1457892945
Name:PETRICKA, GENEVIEVE
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:PETRICKA
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 1:15360 18TH AVE N
Mailing Address - Street 2:APT 1009
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110105 PIONEER TRL
Practice Address - Street 2:SUITE 201
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2680
Practice Address - Country:US
Practice Address - Phone:952-512-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer