Provider Demographics
NPI:1770633398
Name:PETIT, INGEBORG G (MSN, CS, ARNP)
Entity Type:Individual
Prefix:
First Name:INGEBORG
Middle Name:G
Last Name:PETIT
Suffix:
Gender:F
Credentials:MSN, CS, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1217
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:859-254-2743
Practice Address - Street 1:269 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-2126
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:859-254-2743
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3145S363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY0045366Medicare ID - Type UnspecifiedMEDICARE
KY0575109Medicare ID - Type UnspecifiedMEDICARE
KY3311Medicare ID - Type UnspecifiedMEDICARE
KY0331212Medicare ID - Type UnspecifiedMEDICARE
KY0406211Medicare ID - Type UnspecifiedMEDICARE
KYP05632Medicare UPIN
KY0331122Medicare ID - Type UnspecifiedMEDICARE
KY0331314Medicare ID - Type UnspecifiedMEDICARE
KY30615058Medicaid