Provider Demographics
NPI:1568945285
Name:PETTYJOHN, KATHERINE MARCELA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MARCELA
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 COLMA AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-8719
Mailing Address - Country:US
Mailing Address - Phone:209-617-4647
Mailing Address - Fax:209-409-8239
Practice Address - Street 1:1409 LECOURBE CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8905
Practice Address - Country:US
Practice Address - Phone:209-409-8239
Practice Address - Fax:209-409-8239
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009952261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care