Provider Demographics
NPI:1447784236
Name:PETTAWAY, THERESA (PCD,DONA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:PCD,DONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:YEADON
Mailing Address - State:PA
Mailing Address - Zip Code:19050-3336
Mailing Address - Country:US
Mailing Address - Phone:610-394-3515
Mailing Address - Fax:
Practice Address - Street 1:609 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:YEADON
Practice Address - State:PA
Practice Address - Zip Code:19050-3336
Practice Address - Country:US
Practice Address - Phone:610-394-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA233089455Medicaid