Provider Demographics
NPI:1821643362
Name:PETTIGREW, SHANICE C (PTA)
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:C
Last Name:PETTIGREW
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 1:9992 HIGHWAY 1 N
Mailing Address - Street 2:
Mailing Address - City:COLT
Mailing Address - State:AR
Mailing Address - Zip Code:72326-8408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:661 HIGHWAY 64B
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-8506
Practice Address - Country:US
Practice Address - Phone:870-238-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4462225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty