Provider Demographics
NPI:1972981231
Name:VANDEVER, PETULIA
Entity Type:Individual
Prefix:
First Name:PETULIA
Middle Name:
Last Name:VANDEVER
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 1:4321 FULCRUM WAY NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4321 FULCRUM WAY NE
Practice Address - Street 2:SUITE B
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8408
Practice Address - Country:US
Practice Address - Phone:505-867-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator