Provider Demographics
NPI:1013524701
Name:ONTELL, PETTIE
Entity Type:Individual
Prefix:
First Name:PETTIE
Middle Name:
Last Name:ONTELL
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 1:16489 GALA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-1526
Mailing Address - Country:US
Mailing Address - Phone:323-697-4357
Mailing Address - Fax:
Practice Address - Street 1:16489 GALA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-1526
Practice Address - Country:US
Practice Address - Phone:323-697-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-26
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50519225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist