Provider Demographics
NPI:1578151452
Name:KIETUR, ANNETTE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:KIETUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-2729
Mailing Address - Country:US
Mailing Address - Phone:623-337-7831
Mailing Address - Fax:855-978-1317
Practice Address - Street 1:7797 W PARADISE LN STE 130
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5011
Practice Address - Country:US
Practice Address - Phone:623-337-7831
Practice Address - Fax:855-978-1317
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN200321163WW0000X
AZ251944363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WW0000XNursing Service ProvidersRegistered NurseWound Care