Provider Demographics
NPI:1366039588
Name:PETTY-HARTGROVE, LISA (DBA)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:PETTY-HARTGROVE
Suffix:
Gender:F
Credentials:DBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 671
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28053-0671
Mailing Address - Country:US
Mailing Address - Phone:980-404-1809
Mailing Address - Fax:980-352-0704
Practice Address - Street 1:1010 GROVES ST STE 2
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2230
Practice Address - Country:US
Practice Address - Phone:980-404-1809
Practice Address - Fax:980-352-0704
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171W00000XOther Service ProvidersContractor
No174H00000XOther Service ProvidersHealth Educator