Provider Demographics
NPI:1871231837
Name:PEKKE, PETWA
Entity Type:Individual
Prefix:
First Name:PETWA
Middle Name:
Last Name:PEKKE
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 1:1981 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4495
Mailing Address - Country:US
Mailing Address - Phone:831-809-0468
Mailing Address - Fax:
Practice Address - Street 1:1981 YORKTOWN DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4495
Practice Address - Country:US
Practice Address - Phone:831-809-0468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200343164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse