Provider Demographics
NPI:1770361206
Name:PETTIT, DEANNA SHAE (FNP)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:SHAE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 DRU CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4582
Mailing Address - Country:US
Mailing Address - Phone:229-291-5455
Mailing Address - Fax:
Practice Address - Street 1:1712 E BROAD AVE # C
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2611
Practice Address - Country:US
Practice Address - Phone:229-483-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2022137592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily