Healthcare Provider Details

I. General information

NPI: 1922607357
Provider Name (Legal Business Name): LAURA EVELYN PETTIT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 HUNTER DR
PUEBLO CO
81001-1812
US

IV. Provider business mailing address

710 HUNTER DR
PUEBLO CO
81001-1812
US

V. Phone/Fax

Practice location:
  • Phone: 719-225-8246
  • Fax:
Mailing address:
  • Phone: 719-225-8246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0996032-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: