Healthcare Provider Details

I. General information

NPI: 1821584012
Provider Name (Legal Business Name): VIKTORYIA PETRUSEVICH CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E 9TH AVE STE 101
SALT LAKE CITY UT
84103-3186
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number14219578-4402
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number14219578-4402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: