Provider Demographics
NPI:1942935408
Name:PETTAWAY, KERRIANN (DNP)
Entity Type:Individual
Prefix:
First Name:KERRIANN
Middle Name:
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 ROCK FENCE RD SE
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-7004
Mailing Address - Country:US
Mailing Address - Phone:908-917-5992
Mailing Address - Fax:
Practice Address - Street 1:7262 GOVERNORS WEST NW STE 105
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-2378
Practice Address - Country:US
Practice Address - Phone:256-418-9014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-177822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily