Provider Demographics
NPI:1326300732
Name:PETTYJOHN, ALEXANDREA LEE (LMP)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDREA
Middle Name:LEE
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 195TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8858
Mailing Address - Country:US
Mailing Address - Phone:253-709-7070
Mailing Address - Fax:
Practice Address - Street 1:6420 195TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8858
Practice Address - Country:US
Practice Address - Phone:253-709-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60040360247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other