Provider Demographics
NPI:1821584012
Name:PETRUSEVICH, VIKTORYIA (CNM)
Entity type:Individual
Prefix:
First Name:VIKTORYIA
Middle Name:
Last Name:PETRUSEVICH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9479
Mailing Address - Country:US
Mailing Address - Phone:952-215-2742
Mailing Address - Fax:
Practice Address - Street 1:370 E 9TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-3186
Practice Address - Country:US
Practice Address - Phone:801-507-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
UT14219578-4402176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife