Provider Demographics
NPI:1205392560
Name:PETTIT, LANDON EIREEN (A-GNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LANDON
Middle Name:EIREEN
Last Name:PETTIT
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JCT
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-263-2619
Mailing Address - Fax:970-263-2691
Practice Address - Street 1:603 28 1/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JCT
Practice Address - State:CO
Practice Address - Zip Code:81506-6019
Practice Address - Country:US
Practice Address - Phone:970-263-2600
Practice Address - Fax:970-263-2692
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995293-NP363LF0000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORXN.0104530-NPOtherCO RXN
COAPN.0995293OtherCOLORADO LICENSE NUMBER
CORXN.0104530-NPOtherCO RXN