Provider Demographics
NPI:1578349551
Name:PETKUS, SHIVAUGHN (FNP)
Entity Type:Individual
Prefix:
First Name:SHIVAUGHN
Middle Name:
Last Name:PETKUS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 E CARMEL DR STE 309
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2812
Mailing Address - Country:US
Mailing Address - Phone:317-324-8802
Mailing Address - Fax:
Practice Address - Street 1:4519 E 82ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4241
Practice Address - Country:US
Practice Address - Phone:317-849-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014225A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily