Provider Demographics
NPI:1598194771
Name:PETTIT, ANDREA C (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:C
Last Name:PETTIT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10327 CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-2055
Mailing Address - Country:US
Mailing Address - Phone:218-329-2915
Mailing Address - Fax:
Practice Address - Street 1:415 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1264
Practice Address - Country:US
Practice Address - Phone:218-631-7475
Practice Address - Fax:218-632-8765
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1381225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant