Provider Demographics
NPI:1720415748
Name:PETTIT, HEIDI NICOLE (RN, CPNP - PC)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:NICOLE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:RN, CPNP - PC
Other - Prefix:MS
Other - First Name:HEIDI
Other - Middle Name:NICOLE
Other - Last Name:LEISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR # E2300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-7000
Mailing Address - Fax:214-456-5071
Practice Address - Street 1:1935 MEDICAL DISTRICT DR # E2300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-7000
Practice Address - Fax:214-456-5071
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX744225363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics