Provider Demographics
NPI:1225598014
Name:PETTIFORD, TINIKIA SHONTA
Entity Type:Individual
Prefix:MS
First Name:TINIKIA
Middle Name:SHONTA
Last Name:PETTIFORD
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 1:1606 PINECROFT RD APT H
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3804
Mailing Address - Country:US
Mailing Address - Phone:336-419-5148
Mailing Address - Fax:
Practice Address - Street 1:1606 PINECROFT RD APT H
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3804
Practice Address - Country:US
Practice Address - Phone:336-419-5148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health