Provider Demographics
NPI:1770876674
Name:PETTITT, PORTIA JANETTE (AP)
Entity type:Individual
Prefix:DR
First Name:PORTIA
Middle Name:JANETTE
Last Name:PETTITT
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191408
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33119-1408
Mailing Address - Country:US
Mailing Address - Phone:773-307-0694
Mailing Address - Fax:
Practice Address - Street 1:1301 ALTON RD
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-3811
Practice Address - Country:US
Practice Address - Phone:305-531-5994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 2888171100000X
IL198.000656171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist