Provider Demographics
NPI:1508431800
Name:PETTYJOHN, FAITH (NP)
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 ALBEMARLE AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2801
Mailing Address - Country:US
Mailing Address - Phone:267-275-1755
Mailing Address - Fax:
Practice Address - Street 1:4700 WISSAHICKON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-4248
Practice Address - Country:US
Practice Address - Phone:215-967-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023749363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health