Provider Demographics
NPI:1952359200
Name:PETTICREW, DANISE A (RN, FNP-C)
Entity Type:Individual
Prefix:
First Name:DANISE
Middle Name:A
Last Name:PETTICREW
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2130
Mailing Address - Country:US
Mailing Address - Phone:903-595-5486
Mailing Address - Fax:903-595-0206
Practice Address - Street 1:635 STONE AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-9342
Practice Address - Country:US
Practice Address - Phone:903-785-3300
Practice Address - Fax:903-785-3310
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8359N1Medicare ID - Type Unspecified
TX1211765-05Medicaid
TXR91953Medicare UPIN