Provider Demographics
NPI:1558429480
Name:PETTIBON, REX (LMP)
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:
Last Name:PETTIBON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 157TH STREET CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-9070
Mailing Address - Country:US
Mailing Address - Phone:253-565-2225
Mailing Address - Fax:
Practice Address - Street 1:6615 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2027
Practice Address - Country:US
Practice Address - Phone:253-565-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009484225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist