Provider Demographics
NPI:1942884846
Name:PETTIS, ALYSHA
Entity Type:Individual
Prefix:
First Name:ALYSHA
Middle Name:
Last Name:PETTIS
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 1:1829 FOREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-6565
Mailing Address - Country:US
Mailing Address - Phone:352-818-2485
Mailing Address - Fax:
Practice Address - Street 1:1829 FOREST GLEN DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-6565
Practice Address - Country:US
Practice Address - Phone:352-818-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology