Provider Demographics
NPI:1982828059
Name:PETTIGREW, MELISSIA W (PT)
Entity Type:Individual
Prefix:
First Name:MELISSIA
Middle Name:W
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14499 KERR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KEOTA
Mailing Address - State:OK
Mailing Address - Zip Code:74941-6554
Mailing Address - Country:US
Mailing Address - Phone:918-966-3104
Mailing Address - Fax:
Practice Address - Street 1:14499 KERR LAKE RD
Practice Address - Street 2:
Practice Address - City:KEOTA
Practice Address - State:OK
Practice Address - Zip Code:74941-6554
Practice Address - Country:US
Practice Address - Phone:918-966-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist