Provider Demographics
NPI:1568855609
Name:PETTIT, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:PETTIT
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 1:3340 KENSINGTON CT
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3340 KENSINGTON CT
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:WI
Practice Address - Zip Code:53405-4555
Practice Address - Country:US
Practice Address - Phone:262-989-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer