Provider Demographics
NPI:1992511588
Name:PETLAKH, GALINA
Entity type:Individual
Prefix:
First Name:GALINA
Middle Name:
Last Name:PETLAKH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 PURDY ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1795
Mailing Address - Country:US
Mailing Address - Phone:248-320-7295
Mailing Address - Fax:
Practice Address - Street 1:608 PURDY ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-1795
Practice Address - Country:US
Practice Address - Phone:248-320-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
MI4704211679163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty