Provider Demographics
NPI:1104087295
Name:PETITT, ELIZABETH KAYE (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAYE
Last Name:PETITT
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 1:4419 CRENSHAW RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-3628
Mailing Address - Country:US
Mailing Address - Phone:281-991-5944
Mailing Address - Fax:281-991-6129
Practice Address - Street 1:4419 CRENSHAW RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-3628
Practice Address - Country:US
Practice Address - Phone:281-991-5944
Practice Address - Fax:281-991-6129
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618556363LF0000X
TXAP116816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K8483Medicare PIN