Provider Demographics
NPI:1669251229
Name:PETIT, AMANDA (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETIT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 OAKHOLT CT
Mailing Address - Street 2:
Mailing Address - City:HERCULANEUM
Mailing Address - State:MO
Mailing Address - Zip Code:63048-1723
Mailing Address - Country:US
Mailing Address - Phone:314-717-6558
Mailing Address - Fax:
Practice Address - Street 1:1400 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-933-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023007586163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine