Healthcare Provider Details

I. General information

NPI: 1417885534
Provider Name (Legal Business Name): LASHAWNDA PETTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 LAKES DR N
OXFORD MS
38655-9219
US

IV. Provider business mailing address

303 LAKES DR N
OXFORD MS
38655-9219
US

V. Phone/Fax

Practice location:
  • Phone: 662-832-3152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number908407
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: