Healthcare Provider Details

I. General information

NPI: 1750148748
Provider Name (Legal Business Name): ALEXANDRA LAUREN PETTUS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WESTERN AVE STE 204
SAN BERNARDINO CA
92411-1353
US

IV. Provider business mailing address

945 S RIDGECREST CIR
ANAHEIM CA
92807-4502
US

V. Phone/Fax

Practice location:
  • Phone: 909-474-9952
  • Fax:
Mailing address:
  • Phone: 256-620-1972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028213
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: