Basic Information
| Provider Information | |||||||||
| NPI: | 1689755753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETIT | ||||||||
| FirstName: | SONDRA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99335 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177350400 | ||||||||
| FaxNumber: | 8177350111 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 MONTGOMERY ST | ||||||||
| Address2: | DEPT OF OB/GYN | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179271065 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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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 | 363LW0102X | 245715 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 143498702 | 05 | TX | MEDICAID | 8N8815 | 01 | TX | BCBS | OTHER |