Provider Demographics
NPI:1023229085
Name:CRETILLI, PATRICIA K
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:K
Last Name:CRETILLI
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 1:5430 EDGEWATER BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2604
Mailing Address - Country:US
Mailing Address - Phone:612-822-2714
Mailing Address - Fax:
Practice Address - Street 1:5430 EDGEWATER BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2604
Practice Address - Country:US
Practice Address - Phone:612-822-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 078381 9163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN77D30CROtherBLUE CROSS BLUE SHIELD