Provider Demographics
NPI:1285383216
Name:PETTMAN, MARCI LYNN (PT)
Entity type:Individual
Prefix:
First Name:MARCI
Middle Name:LYNN
Last Name:PETTMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARCI
Other - Middle Name:LYNN
Other - Last Name:DANIELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1939 MINNEHAHA AVE W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1033
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:11800 XEON BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-2061
Practice Address - Country:US
Practice Address - Phone:763-489-3638
Practice Address - Fax:763-647-3885
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist