Provider Demographics
NPI:1851867014
Name:PETTIT, WYLETTA
Entity Type:Individual
Prefix:
First Name:WYLETTA
Middle Name:
Last Name:PETTIT
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 1:607 N POLK AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-2713
Mailing Address - Country:US
Mailing Address - Phone:918-304-4371
Mailing Address - Fax:
Practice Address - Street 1:607 N POLK AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-2713
Practice Address - Country:US
Practice Address - Phone:918-304-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist