Provider Demographics
NPI:1770904682
Name:PETTIS, LIDIA
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:PETTIS
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 1:1760 N DECATUR BLVD
Mailing Address - Street 2:79
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2208
Mailing Address - Country:US
Mailing Address - Phone:702-810-9742
Mailing Address - Fax:
Practice Address - Street 1:1760 N DECATUR BLVD
Practice Address - Street 2:79
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-2208
Practice Address - Country:US
Practice Address - Phone:702-810-9742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner