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General NPI Number Information
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NPI Number | 1568945285
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Entity Type | Individual
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Provider Name | KATHERINE MARCELA PETTYJOHN FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 09/09/2018
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Last Update Date | 09/09/2018
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Provider Practice Location Address
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Address Line | 1409 LECOURBE CT
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City | MODESTO
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State | CA
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Zip | 95356-8905
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Country | US
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Telephone | 209-409-8239
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Fax | 209-409-8239
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Provider Business Mailing Address
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Address Line | 3880 COLMA AVE
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City | MERCED
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State | CA
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Zip | 95348-8719
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Country | US
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Telephone | 209-617-4647
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Fax | 209-409-8239
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 95009952
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License Number State | CA
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