Healthcare Provider Details

I. General information

NPI: 1063593523
Provider Name (Legal Business Name): LINDA ANN PETTIT CLINICAL NURSE SPECI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 E SPRING VALLEY RD B
CENTERVILLE OH
45458-3803
US

IV. Provider business mailing address

180 E SPRING VALLEY RD STE B
CENTERVILLE OH
45458-3803
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-1351
  • Fax: 937-291-1719
Mailing address:
  • Phone: 937-291-1351
  • Fax: 937-291-1719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberNS03049
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: