Provider Demographics
NPI:1982213773
Name:PETTREY, MALYNN
Entity Type:Individual
Prefix:
First Name:MALYNN
Middle Name:
Last Name:PETTREY
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 1:1912 BENT MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LERONA
Mailing Address - State:WV
Mailing Address - Zip Code:25971-9476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1912 BENT MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:LERONA
Practice Address - State:WV
Practice Address - Zip Code:25971-9476
Practice Address - Country:US
Practice Address - Phone:304-252-3394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator