Provider Demographics
NPI:1710409610
Name:PETTUS, SHONTE'E ELAINE
Entity Type:Individual
Prefix:
First Name:SHONTE'E
Middle Name:ELAINE
Last Name:PETTUS
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 1:44200 KINGTREE AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4115
Mailing Address - Country:US
Mailing Address - Phone:661-208-5444
Mailing Address - Fax:
Practice Address - Street 1:14660 OXNARD ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-3119
Practice Address - Country:US
Practice Address - Phone:818-901-4836
Practice Address - Fax:818-376-0044
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner