Provider Demographics
NPI:1891195970
Name:PETTIT, KRYSTAL (LVN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8534 FAIRMONT WAY
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2908
Mailing Address - Country:US
Mailing Address - Phone:916-965-3821
Mailing Address - Fax:
Practice Address - Street 1:8534 FAIRMONT WAY
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-2908
Practice Address - Country:US
Practice Address - Phone:916-965-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN278584164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse