Healthcare Provider Details

I. General information

NPI: 1508302761
Provider Name (Legal Business Name): ERIC JUSTIN PETTITT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LANDINGS DR
LYNN HAVEN FL
32444-3242
US

IV. Provider business mailing address

12176 83RD LN N
WEST PALM BEACH FL
33412-2288
US

V. Phone/Fax

Practice location:
  • Phone: 850-292-2431
  • Fax:
Mailing address:
  • Phone: 850-292-2431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9346602
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: