Healthcare Provider Details

I. General information

NPI: 1396743605
Provider Name (Legal Business Name): MARIA M. PETRICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA M. PALMIERI

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 STONY POINT RD SUITE E
SANTA ROSA CA
95401-4120
US

IV. Provider business mailing address

130 STONY POINT RD SUITE E
SANTA ROSA CA
95401-4120
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-0211
  • Fax: 707-525-0491
Mailing address:
  • Phone: 707-525-0211
  • Fax: 707-525-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number40808
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number01063403A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberC132754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: