Provider Demographics
NPI:1225502156
Name:PETTIECORD, KRISTY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:PETTIECORD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:LYNN
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1423 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SNEEDVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37869-3654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1423 MAIN ST
Practice Address - Street 2:
Practice Address - City:SNEEDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37869-3654
Practice Address - Country:US
Practice Address - Phone:423-733-4783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6835225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant