Healthcare Provider Details

I. General information

NPI: 1356629802
Provider Name (Legal Business Name): TRISHA MARY PETITTE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 FRONT STREET
MOUNT MORRIS PA
15349
US

IV. Provider business mailing address

PO BOX 9190
MORGANTOWN WV
26506-9190
US

V. Phone/Fax

Practice location:
  • Phone: 724-324-9001
  • Fax:
Mailing address:
  • Phone: 304-293-1084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP011429
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: