Provider Demographics
NPI:1427157171
Name:PETRACK, CYNTHIA J (APRN-BC)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:J
Last Name:PETRACK
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19010 HILTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1721
Mailing Address - Country:US
Mailing Address - Phone:248-352-5831
Mailing Address - Fax:248-352-4204
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-8025
Practice Address - Fax:248-849-8256
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704130122363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health