Provider Demographics
NPI:1245617349
Name:PETTIT, ROBIN DIANE (RN,PHN)
Entity Type:Individual
Prefix:MRS
First Name:ROBIN
Middle Name:DIANE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:RN,PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 CENTRE POINTE BLVD
Mailing Address - Street 2:SUITE # 3
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1269
Mailing Address - Country:US
Mailing Address - Phone:651-774-0011
Mailing Address - Fax:
Practice Address - Street 1:317 YORK AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4039
Practice Address - Country:US
Practice Address - Phone:651-774-0202
Practice Address - Fax:651-774-5517
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-132456-5163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse