Provider Demographics
NPI:1982016549
Name:PETTEWAY, JULIA F (RN)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:F
Last Name:PETTEWAY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 BARNET MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:NC
Mailing Address - Zip Code:28753-9792
Mailing Address - Country:US
Mailing Address - Phone:720-244-2023
Mailing Address - Fax:
Practice Address - Street 1:390 BARNET MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:NC
Practice Address - Zip Code:28753-9792
Practice Address - Country:US
Practice Address - Phone:720-244-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0004203225700000X
NC342310163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT.0004203OtherCOLORADO STATE MASSAGE LICENSE NUMBER