Basic Information
| Provider Information | |||||||||
| NPI: | 1073500914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3211 DUDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261041813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044223904 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044242590 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 56061 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2366845 | 05 | OH | MEDICAID | 2604247000 | 05 | WV | MEDICAID |