Provider Demographics
NPI:1992362248
Name:PETTAWAY, ISHONDA SHANICE (LPN)
Entity Type:Individual
Prefix:
First Name:ISHONDA
Middle Name:SHANICE
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 WILLYS PKWY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1216
Mailing Address - Country:US
Mailing Address - Phone:567-312-3896
Mailing Address - Fax:
Practice Address - Street 1:3941 WILLYS PKWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1216
Practice Address - Country:US
Practice Address - Phone:567-312-3896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170748164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLPN-170748OtherLPN