Healthcare Provider Details

I. General information

NPI: 1952359200
Provider Name (Legal Business Name): DANISE A PETTICREW RN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 STONE AVE
PARIS TX
75460-9342
US

IV. Provider business mailing address

1133 MEDICAL DR
TYLER TX
75701-2130
US

V. Phone/Fax

Practice location:
  • Phone: 903-785-3300
  • Fax: 903-785-3310
Mailing address:
  • Phone: 903-595-5486
  • Fax: 903-595-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number249797
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: