Provider Demographics
NPI:1639493562
Name:PETITTO, RENEE JEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:JEAN
Last Name:PETITTO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1201
Mailing Address - Country:US
Mailing Address - Phone:315-782-0440
Mailing Address - Fax:315-782-5349
Practice Address - Street 1:21101 STATE ROUTE 12F
Practice Address - Street 2:SUITE 5
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1078
Practice Address - Country:US
Practice Address - Phone:315-782-0440
Practice Address - Fax:315-782-5349
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012216111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400128475Medicare PIN