Provider Demographics
NPI:1003392812
Name:PETTIT, LEO DILLON (LMT)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:DILLON
Last Name:PETTIT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10823 E PALMER WASILLA HWY STE 4
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-9498
Mailing Address - Country:US
Mailing Address - Phone:907-707-3847
Mailing Address - Fax:
Practice Address - Street 1:10823 E PALMER WASILLA HWY STE 4
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9498
Practice Address - Country:US
Practice Address - Phone:907-707-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK133088225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist