Healthcare Provider Details

I. General information

NPI: 1902577414
Provider Name (Legal Business Name): AMBER PETCULESCU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W MEMORIAL DR
ANTHEM AZ
85086-4955
US

IV. Provider business mailing address

44047 N 43RD AVE UNIT 74961
PHOENIX AZ
85087-6050
US

V. Phone/Fax

Practice location:
  • Phone: 623-445-7410
  • Fax:
Mailing address:
  • Phone: 623-210-5758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN174775
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: