Provider Demographics
NPI:1225701303
Name:PETTEWAY, BREONA
Entity Type:Individual
Prefix:
First Name:BREONA
Middle Name:
Last Name:PETTEWAY
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 1:108 W ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-2527
Mailing Address - Country:US
Mailing Address - Phone:631-636-1772
Mailing Address - Fax:
Practice Address - Street 1:206 ERIE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-1608
Practice Address - Country:US
Practice Address - Phone:631-636-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331074-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse