Provider Demographics
NPI:1811390396
Name:PETTIS, EMILY BROOKE (CRNP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BROOKE
Last Name:PETTIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 ROSS CLARK CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3023
Mailing Address - Country:US
Mailing Address - Phone:334-794-1148
Mailing Address - Fax:
Practice Address - Street 1:1118 ROSS CLARK CIR STE 100
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3023
Practice Address - Country:US
Practice Address - Phone:334-794-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAG0114029363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health