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NPI Code Detail

MEDICARE: KESHIA PETTUS

MEDICARE: KESHIA PETTUS
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
1363LF0000XFamily Nurse Practitioner5004129NC

General Provider Information

NPI Number : 1629229851
Entity Type Code : Individual
Provider Name (Legal Business Name) : KESHIA PETTUS
Provider Business Mailing Address
First Line : 10515 MALLARD CREEK RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28262-9785
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 10515 MALLARD CREEK RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28262-9785
Country : US
Telephone Number : 704-547-9739
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/07/2008
Last Update Date : 01/23/2009

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Directions to “ KESHIA PETTUS ” Practice Location

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