MEDICARE: CHELSEY PETTIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1-098965	AL

General Provider Information

NPI Number	:	1346799871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELSEY PETTIS

Provider Business Mailing Address
First Line	:	101 CRESTVIEW AVE
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3333
Country	:	US
Telephone Number	:	251-578-2480
Fax Number	:	251-578-1055

Provider Business Practice Location Address
First Line	:	100 EDWINA ST
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3319
Country	:	US
Telephone Number	:	251-578-0278
Fax Number	:	251-578-1055

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	09/26/2016

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Directions to “ CHELSEY PETTIS ” Practice Location

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