Provider Demographics
NPI:1972080331
Name:PETTIT, NANCY HALL (PA-C)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:HALL
Last Name:PETTIT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29824 290TH ST
Mailing Address - Street 2:PO BOX 405
Mailing Address - City:NEOLA
Mailing Address - State:IA
Mailing Address - Zip Code:51559-0405
Mailing Address - Country:US
Mailing Address - Phone:712-485-2693
Mailing Address - Fax:
Practice Address - Street 1:320 MCKENZIE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-256-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty