Provider Demographics
NPI:1134740004
Name:PETTY-MILIKEN, KERTONNIA
Entity type:Individual
Prefix:
First Name:KERTONNIA
Middle Name:
Last Name:PETTY-MILIKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KERTONNIA
Other - Middle Name:
Other - Last Name:PETTY-MILIKEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37092
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-1592
Mailing Address - Country:US
Mailing Address - Phone:314-666-4041
Mailing Address - Fax:
Practice Address - Street 1:2570 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-3611
Practice Address - Country:US
Practice Address - Phone:314-666-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator