Provider Demographics
NPI:1750404612
Name:PETROVICH, MARLENE LOUISE (MSN)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:LOUISE
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1640 FORT ST
Mailing Address - Street 2:SUITE D ATTN DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2040
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:23050 WEST RD
Practice Address - Street 2:SUITE210
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1472
Practice Address - Country:US
Practice Address - Phone:734-362-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704100811363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144634403OtherGROUP NPI HENRY FORD WYANDOTTE
MI0H28865OtherBLUE CROSS
MI0H28865OtherBLUE CROSS