Healthcare Provider Details

I. General information

NPI: 1841968898
Provider Name (Legal Business Name): KATHERINE LEE PETKOVICH DNP, RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 E ADOBE ST
MESA AZ
85213-6740
US

IV. Provider business mailing address

2017 E ADOBE ST
MESA AZ
85213-6740
US

V. Phone/Fax

Practice location:
  • Phone: 480-244-5373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number323837
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN215094
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: