Basic Information
| Provider Information | |||||||||
| NPI: | 1326062845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTRY | ||||||||
| FirstName: | NANETTE | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 BROOKWOOD BLVD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058700256 | ||||||||
| FaxNumber: | 2058707107 | ||||||||
| Practice Location | |||||||||
| Address1: | 513 BROOKWOOD BLVD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058700256 | ||||||||
| FaxNumber: | 2058707107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1-056480 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 51530417 | 01 | AL | BLUE CROSS | OTHER |