Provider Demographics
NPI:1649457706
Name:PETTIS, ANGELA PATRICE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:PATRICE
Last Name:PETTIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 FARMINGTON RD W
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-9767
Mailing Address - Country:US
Mailing Address - Phone:301-292-3959
Mailing Address - Fax:
Practice Address - Street 1:1050 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:ANDREWS AFB
Practice Address - State:MD
Practice Address - Zip Code:20762-6601
Practice Address - Country:US
Practice Address - Phone:240-857-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR153416163W00000X
VA0024169705367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse