Provider Demographics
NPI:1417760612
Name:PETTIT, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETTIT
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 1:1257 RACY RD
Mailing Address - Street 2:
Mailing Address - City:PETROLEUM
Mailing Address - State:WV
Mailing Address - Zip Code:26161-6530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1257 RACY RD
Practice Address - Street 2:
Practice Address - City:PETROLEUM
Practice Address - State:WV
Practice Address - Zip Code:26161-6530
Practice Address - Country:US
Practice Address - Phone:304-508-8959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant