Healthcare Provider Details

I. General information

NPI: 1770888588
Provider Name (Legal Business Name): NICHOLAS DAVID PETRINI DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 ROOSEVELT WAY NE STE 101
SEATTLE WA
98105-6579
US

IV. Provider business mailing address

5534 84TH DR NE
MARYSVILLE WA
98270-8509
US

V. Phone/Fax

Practice location:
  • Phone: 203-312-3894
  • Fax:
Mailing address:
  • Phone: 203-312-3894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60647239
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberX012149-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCH60647239
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: