Provider Demographics
NPI:1902133143
Name:PETTIS, SHAUNA (ANP)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:PETTIS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11207 BARNSWALLOW PL APT E
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4837
Mailing Address - Country:US
Mailing Address - Phone:414-748-7776
Mailing Address - Fax:
Practice Address - Street 1:7450 ALBERT RD FL 2
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3035
Practice Address - Country:US
Practice Address - Phone:301-888-2233
Practice Address - Fax:301-888-9133
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215472363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD444563500Medicaid