Healthcare Provider Details

I. General information

NPI: 1831021633
Provider Name (Legal Business Name): PATRICE MARIE PETTITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 COOPER HILL RD
WYNANTSKILL NY
12198-2906
US

IV. Provider business mailing address

209 STEWART POINT RD
NASSAU NY
12123-3123
US

V. Phone/Fax

Practice location:
  • Phone: 518-283-6500
  • Fax: 518-283-3013
Mailing address:
  • Phone: 518-283-6500
  • Fax: 518-283-3013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number500195-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: