=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699665521
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. NIKITA S PETTIES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2025
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 BROADUS ST
-----------------------------------------------------
City | STURGIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49091-1384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-549-1015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3355 WATERSHED BLVD
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20724-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-549-1015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------