Provider Demographics
NPI:1104582097
Name:PETTIS, PATRICIA ANN (APRN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:PETTIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHATTUCK WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-8007
Mailing Address - Country:US
Mailing Address - Phone:603-431-6677
Mailing Address - Fax:603-610-2232
Practice Address - Street 1:100 SHATTUCK WAY STE 100
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:NH
Practice Address - Zip Code:03801-8007
Practice Address - Country:US
Practice Address - Phone:603-431-6677
Practice Address - Fax:603-610-2232
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH031898-232080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine