Provider Demographics
NPI:1265414544
Name:PETECH, KERRIE L (RN ARNP-CNP)
Entity type:Individual
Prefix:
First Name:KERRIE
Middle Name:L
Last Name:PETECH
Suffix:
Gender:F
Credentials:RN ARNP-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 S TOPAZ WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4401
Mailing Address - Country:US
Mailing Address - Phone:208-209-2432
Mailing Address - Fax:
Practice Address - Street 1:1859 S TOPAZ WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4401
Practice Address - Country:US
Practice Address - Phone:208-209-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60178019163W00000X
WAAP61405417363LP0808X
ID74724363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse