Provider Demographics
NPI:1932352143
Name:PETTIT, CHRISTINE (APRN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ASHLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-1912
Mailing Address - Country:US
Mailing Address - Phone:845-326-8045
Mailing Address - Fax:
Practice Address - Street 1:45 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-1912
Practice Address - Country:US
Practice Address - Phone:845-326-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401177363LP0808X
SC4417363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA63393334OtherMEDICARE PTAN
SC1760596480Medicaid