Provider Demographics
NPI:1346896412
Name:PETTWAY, ALEXIS (ATC)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 N PALM AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4624
Mailing Address - Country:US
Mailing Address - Phone:909-562-5534
Mailing Address - Fax:
Practice Address - Street 1:13847 EARLHAM DRIVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602
Practice Address - Country:US
Practice Address - Phone:562-907-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20000073782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer