Provider Demographics
NPI:1750511911
Name:PETTIGREW-WHEATON, VIRGINIA LOLA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LOLA
Last Name:PETTIGREW-WHEATON
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 1:3976 KING GRAVES RD
Mailing Address - Street 2:910TH MDS (AFRC)
Mailing Address - City:VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44473-6900
Mailing Address - Country:US
Mailing Address - Phone:330-609-1233
Mailing Address - Fax:
Practice Address - Street 1:3976 KING GRAVES RD
Practice Address - Street 2:910TH MDS (AFRC)
Practice Address - City:VIENNA
Practice Address - State:OH
Practice Address - Zip Code:44473-6900
Practice Address - Country:US
Practice Address - Phone:330-609-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians