Provider Demographics
NPI:1689033680
Name:PETRICEK, URSULA
Entity type:Individual
Prefix:MRS
First Name:URSULA
Middle Name:
Last Name:PETRICEK
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 1:900 ROUTE 376
Mailing Address - Street 2:SUITE H
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-6494
Mailing Address - Country:US
Mailing Address - Phone:845-204-9260
Mailing Address - Fax:
Practice Address - Street 1:900 ROUTE 376
Practice Address - Street 2:SUITE H
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-6494
Practice Address - Country:US
Practice Address - Phone:845-204-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9014519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily