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NPI Code Detail

MEDICARE: KATELYN PETROVICH PMHNP-BC

MEDICARE: KATELYN PETROVICH PMHNP-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse PractitionerAP126794TX

General Provider Information

NPI Number : 1730584988
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATELYN PETROVICH PMHNP-BC
Provider Business Mailing Address
First Line : 1480 BOSTON POST RD
Second Line :
City : OLD SAYBROOK
State : CT
Zip : 06475-1750
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 211 E 7TH ST STE 620
Second Line :
City : AUSTIN
State : TX
Zip : 78701-3218
Country : US
Telephone Number : 800-370-3651
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/30/2014
Last Update Date : 12/15/2020

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