Healthcare Provider Details

I. General information

NPI: 1073674628
Provider Name (Legal Business Name): DIANE CLARE PETTIT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WRAMC RM 2J38 6900 GEORGIA AVE
WASHINGTON DC
20307-0001
US

IV. Provider business mailing address

2 WRAMC ROOM 2J38 6900 GEORGIA AVE
WASHINGTON DC
20307-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-6114
  • Fax:
Mailing address:
  • Phone: 202-782-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR041390
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: