Healthcare Provider Details

I. General information

NPI: 1811390396
Provider Name (Legal Business Name): EMILY BROOKE PETTIS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSS CLARK CIR STE 100
DOTHAN AL
36301-3023
US

IV. Provider business mailing address

1118 ROSS CLARK CIR STE 100
DOTHAN AL
36301-3023
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-1148
  • Fax:
Mailing address:
  • Phone: 334-794-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG0114029
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: