Provider Demographics
NPI:1033813753
Name:PETTUS, TAMEKA
Entity Type:Individual
Prefix:
First Name:TAMEKA
Middle Name:
Last Name:PETTUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 E CAPITOL ST SE APT 102
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-4478
Mailing Address - Country:US
Mailing Address - Phone:120-260-2920
Mailing Address - Fax:
Practice Address - Street 1:915 RHODE ISLAND AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-4153
Practice Address - Country:US
Practice Address - Phone:202-914-6951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator