Provider Demographics
NPI:1275165516
Name:PETTIS, ELIZABETH M
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:PETTIS
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 1:6868 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1604
Mailing Address - Country:US
Mailing Address - Phone:414-254-9434
Mailing Address - Fax:414-215-7227
Practice Address - Street 1:6868 S ASH ST
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1604
Practice Address - Country:US
Practice Address - Phone:414-254-9434
Practice Address - Fax:414-215-7227
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100067661Medicaid