Healthcare Provider Details

I. General information

NPI: 1023229085
Provider Name (Legal Business Name): PATRICIA K. CRETILLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 EDGEWATER BLVD
MINNEAPOLIS MN
55417-2604
US

IV. Provider business mailing address

5430 EDGEWATER BLVD
MINNEAPOLIS MN
55417-2604
US

V. Phone/Fax

Practice location:
  • Phone: 612-822-2714
  • Fax:
Mailing address:
  • Phone: 612-822-2714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR 078381 9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: