Provider Demographics
NPI:1073904553
Name:PITTAWAY, AMBER (PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:
Last Name:PITTAWAY
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5867 NORTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1870
Mailing Address - Country:US
Mailing Address - Phone:248-568-4533
Mailing Address - Fax:
Practice Address - Street 1:5867 NORTHRIDGE CIR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1870
Practice Address - Country:US
Practice Address - Phone:248-568-4533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH630066493409172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker