Provider Demographics
NPI:1144670837
Name:PETRICK, NICOLE M (LMP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:PETRICK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17059 156TH PL SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2701
Mailing Address - Country:US
Mailing Address - Phone:425-870-6932
Mailing Address - Fax:
Practice Address - Street 1:603 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2101
Practice Address - Country:US
Practice Address - Phone:360-805-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60405050225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist