Provider Demographics
NPI:1164789418
Name:PETTIT, HOLLY JO (LPN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JO
Last Name:PETTIT
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 1:801 LAKEFIED DRIVE
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119
Mailing Address - Country:US
Mailing Address - Phone:614-638-7383
Mailing Address - Fax:
Practice Address - Street 1:801 LAKEFIELD DR
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-9020
Practice Address - Country:US
Practice Address - Phone:614-638-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN118067 M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse