Provider Demographics
NPI:1730432238
Name:PETRON, ELLEN JILL (CMT)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:JILL
Last Name:PETRON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:401 DEWEY STREET
Mailing Address - City:FOLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56329-0570
Mailing Address - Country:US
Mailing Address - Phone:320-968-7413
Mailing Address - Fax:
Practice Address - Street 1:401 DEWEY ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:MN
Practice Address - Zip Code:56329-8406
Practice Address - Country:US
Practice Address - Phone:320-968-7413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist