Provider Demographics
NPI:1972339760
Name:PETTYJOHN, ENA (FNP-C)
Entity type:Individual
Prefix:
First Name:ENA
Middle Name:
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7552 BEAUCHAMP CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-1550
Mailing Address - Country:US
Mailing Address - Phone:804-815-5399
Mailing Address - Fax:
Practice Address - Street 1:100 WASHINGTON AVE S STE 1210
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-2511
Practice Address - Country:US
Practice Address - Phone:800-925-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAF08240235363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner