Healthcare Provider Details

I. General information

NPI: 1629127097
Provider Name (Legal Business Name): SUSANNE MARIE PETRICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N HORNE ST
GILBERT AZ
85233-4100
US

IV. Provider business mailing address

550 N HORNE ST
GILBERT AZ
85233-4100
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-7810
  • Fax: 480-892-8842
Mailing address:
  • Phone: 480-892-7810
  • Fax: 480-892-8842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN133014
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: