Healthcare Provider Details

I. General information

NPI: 1235815358
Provider Name (Legal Business Name): MISS ANGIE PETRAKIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5241 N MAPLE AVE
FRESNO CA
93740-0001
US

IV. Provider business mailing address

12347 N VIA IL PRATO AVE
CLOVIS CA
93619-8733
US

V. Phone/Fax

Practice location:
  • Phone: 559-278-4240
  • Fax:
Mailing address:
  • Phone: 559-906-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: