Healthcare Provider Details

I. General information

NPI: 1265296685
Provider Name (Legal Business Name): SELINA PETSCHEK CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22725 44TH AVE W STE 101
MOUNTLAKE TERRACE WA
98043-4500
US

IV. Provider business mailing address

22725 44TH AVE W STE 101
MOUNTLAKE TERRACE WA
98043-4500
US

V. Phone/Fax

Practice location:
  • Phone: 206-371-0945
  • Fax: 425-420-2941
Mailing address:
  • Phone: 206-371-0945
  • Fax: 425-420-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP61553840
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61577055
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: