Provider Demographics
NPI:1841487972
Name:PETTIT, BRYAN KEITH (RN, CCM)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:PETTIT
Suffix:
Gender:M
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-0474
Mailing Address - Country:US
Mailing Address - Phone:740-286-8646
Mailing Address - Fax:740-286-4676
Practice Address - Street 1:5555 GLENDON CT
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-3249
Practice Address - Country:US
Practice Address - Phone:877-641-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00049080OtherCCM
OHRN262281OtherOH BOARD OF NURSING