Provider Demographics
NPI:1376043174
Name:PETTWAY, TINA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-9339
Mailing Address - Country:US
Mailing Address - Phone:256-337-7747
Mailing Address - Fax:
Practice Address - Street 1:4040 MEMORIAL PKWY SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-4364
Practice Address - Country:US
Practice Address - Phone:256-533-1970
Practice Address - Fax:256-705-6477
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-065334164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid