=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932657806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBIN LEE PETRICH APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2016
-----------------------------------------------------
Last Update Date | 05/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 E MAIN ST
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-442-9354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8902 GOULD RD
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55347-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-240-4560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP 4794
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4794
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------