Provider Demographics
NPI:1477390607
Name:PETTYJOHN, SYDNEY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ROSS CT
Mailing Address - Street 2:
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-6711
Mailing Address - Country:US
Mailing Address - Phone:817-726-8819
Mailing Address - Fax:
Practice Address - Street 1:7 ROSS CT
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-6711
Practice Address - Country:US
Practice Address - Phone:817-726-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-311756163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant