Provider Demographics
NPI:1053056143
Name:PETTIS, ANGELA CHRISTINE (LPN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:CHRISTINE
Last Name:PETTIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MERAMEC TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3331
Mailing Address - Country:US
Mailing Address - Phone:636-923-2399
Mailing Address - Fax:
Practice Address - Street 1:1 MERAMEC BLUFFS DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-3309
Practice Address - Country:US
Practice Address - Phone:636-923-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003026650164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse