Healthcare Provider Details

I. General information

NPI: 1487200853
Provider Name (Legal Business Name): ANDREW SPENCER PETTIT DNP, NP, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 E 4500 S STE 300
MURRAY UT
84107-8535
US

IV. Provider business mailing address

PO BOX 198560
ATLANTA GA
30384-8560
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-2777
  • Fax: 801-266-1377
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8671455-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: