Basic Information
| Provider Information | |||||||||
| NPI: | 1902133143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIS | ||||||||
| FirstName: | SHAUNA | ||||||||
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| Credential: | AGNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11207 BARNSWALLOW PL APT E | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147487776 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7450 ALBERT RD | ||||||||
| Address2: | |||||||||
| City: | BRANDYWINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206133035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018882233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | R215472 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.