MEDICARE: ASHLEY PETTITT

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	163WE0003X	Emergency Registered Nurse	RN9250245	FL

General Provider Information

NPI Number	:	1538004080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY PETTITT

Provider Business Mailing Address
First Line	:	209 HERITAGE PARK LN
Second Line	:
City	:	MULBERRY
State	:	FL
Zip	:	33860-9452
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 S FLORIDA AVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-3306
Country	:	US
Telephone Number	:	863-687-0566
Fax Number	:

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

Provider Enumeration Date	:	04/21/2026
Last Update Date	:	04/21/2026

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Directions to “ ASHLEY PETTITT ” Practice Location

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