Provider Demographics
NPI:1023698958
Name:PETIT, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:PETIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 W EVANSTON CIR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-2612
Mailing Address - Country:US
Mailing Address - Phone:754-779-1062
Mailing Address - Fax:
Practice Address - Street 1:637 W EVANSTON CIR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-2612
Practice Address - Country:US
Practice Address - Phone:754-779-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FL374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174400000XOther Service ProvidersSpecialist