Provider Demographics
NPI:1073674628
Name:PETTIT, DIANE CLARE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:CLARE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WRAMC ROOM 2J38
Mailing Address - Street 2:6900 GEORGIA AVE
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20307-0001
Mailing Address - Country:US
Mailing Address - Phone:202-782-6114
Mailing Address - Fax:
Practice Address - Street 1:2 WRAMC RM 2J38
Practice Address - Street 2:6900 GEORGIA AVE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-0001
Practice Address - Country:US
Practice Address - Phone:202-782-6114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR041390363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health