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General NPI Number Information
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NPI Number | 1649386319
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Entity Type | Individual
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Provider Name | AMY VIOLA PETRIE PAC
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Gender | Female
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Dates
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Enumeration Date | 08/22/2006
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Last Update Date | 03/14/2013
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Provider Practice Location Address
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Address Line | 2002 S 11TH ST
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City | NILES
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State | MI
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Zip | 49120-4074
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Country | US
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Telephone | 269-687-0200
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Fax | 269-684-0199
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Provider Business Mailing Address
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Address Line | 6416 DEANS HILL RD
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City | BERRIEN CENTER
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State | MI
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Zip | 49102-9750
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Country | US
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Telephone | 269-471-7741
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Fax | 269-471-1581
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085002713
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601006305
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License Number State | MI
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