Provider Demographics
NPI:1073935839
Name:PETTYJOHN, ANGELENA
Entity Type:Individual
Prefix:
First Name:ANGELENA
Middle Name:
Last Name:PETTYJOHN
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 1:19307 E CATALDO AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99016-9489
Mailing Address - Country:US
Mailing Address - Phone:509-228-5400
Mailing Address - Fax:509-228-5439
Practice Address - Street 1:19307 E CATALDO AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-9489
Practice Address - Country:US
Practice Address - Phone:509-228-5400
Practice Address - Fax:509-228-5439
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60421807235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist