Provider Demographics
NPI:1992520365
Name:PETRIKEN, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:PETRIKEN
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 1:5035 E RUSSELL RD APT 3033
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-8049
Mailing Address - Country:US
Mailing Address - Phone:810-874-5455
Mailing Address - Fax:
Practice Address - Street 1:5035 E RUSSELL RD APT 3033
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-8049
Practice Address - Country:US
Practice Address - Phone:810-874-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV848815163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse