Basic Information
| Provider Information | |||||||||
| NPI: | 1104582097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIS | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SHATTUCK WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038018007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034316677 | ||||||||
| FaxNumber: | 6036102232 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SHATTUCK WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038018007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034316677 | ||||||||
| FaxNumber: | 6036102232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2021 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 031898-23 | NH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.