Provider Demographics
NPI:1518486620
Name:PETTAWAY, MITTIE R
Entity Type:Individual
Prefix:
First Name:MITTIE
Middle Name:R
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-2727
Mailing Address - Country:US
Mailing Address - Phone:301-789-4064
Mailing Address - Fax:
Practice Address - Street 1:3014 LOGAN ST
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-2727
Practice Address - Country:US
Practice Address - Phone:301-789-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant