Healthcare Provider Details

I. General information

NPI: 1992511588
Provider Name (Legal Business Name): GALINA PETLAKH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 PURDY ST
BIRMINGHAM MI
48009-1795
US

IV. Provider business mailing address

608 PURDY ST
BIRMINGHAM MI
48009-1795
US

V. Phone/Fax

Practice location:
  • Phone: 248-320-7295
  • Fax:
Mailing address:
  • Phone: 248-320-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number4704211679
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: