Provider Demographics
NPI:1750825279
Name:PETTIGREW, KELLY LYNN (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LYNN
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PARKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13417-1427
Mailing Address - Country:US
Mailing Address - Phone:315-272-9213
Mailing Address - Fax:
Practice Address - Street 1:35 PARKSIDE CT
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:NY
Practice Address - Zip Code:13417-1427
Practice Address - Country:US
Practice Address - Phone:315-272-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021138-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021138-1OtherNYS LICENSE