Provider Demographics
NPI:1336422377
Name:PETTWAY, LATISHA MONIQUE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:MONIQUE
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1236
Mailing Address - Country:US
Mailing Address - Phone:203-387-7163
Mailing Address - Fax:
Practice Address - Street 1:1423 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4411
Practice Address - Country:US
Practice Address - Phone:203-865-3852
Practice Address - Fax:203-865-2983
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4954367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered