Provider Demographics
NPI:1134536683
Name:PETTIJOHN, CAROLINE ROSE (ATC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ROSE
Last Name:PETTIJOHN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:ROSE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8600 N HICKORY ST
Mailing Address - Street 2:APT 512
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-4103
Mailing Address - Country:US
Mailing Address - Phone:314-608-1112
Mailing Address - Fax:
Practice Address - Street 1:8600 N HICKORY ST
Practice Address - Street 2:APT 512
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-4103
Practice Address - Country:US
Practice Address - Phone:314-608-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer