Healthcare Provider Details

I. General information

NPI: 1972339760
Provider Name (Legal Business Name): ENA PETTYJOHN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON AVE S STE 1210
MINNEAPOLIS MN
55401-2511
US

IV. Provider business mailing address

7552 BEAUCHAMP CT
RICHMOND VA
23225-1550
US

V. Phone/Fax

Practice location:
  • Phone: 800-925-3368
  • Fax:
Mailing address:
  • Phone: 804-815-5399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF08240235
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: