Provider Demographics
NPI:1255431839
Name:PETTIT, RICHARD K (RNFA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:K
Last Name:PETTIT
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7167
Mailing Address - Country:US
Mailing Address - Phone:951-571-3480
Mailing Address - Fax:
Practice Address - Street 1:1150 N INDIAN CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4872
Practice Address - Country:US
Practice Address - Phone:760-323-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438088163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA438088OtherREGISTERED NURSE LICENSE