Basic Information
| Provider Information | |||||||||
| NPI: | 1477725299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DIETITIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416283832 | ||||||||
| FaxNumber: | 6416288894 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416283832 | ||||||||
| FaxNumber: | 6416288894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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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 | 133V00000X | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 16915 | 01 | AMERICAN DIETETIC ASSOC. | OTHER |