Provider Demographics
NPI:1780271320
Name:PETTRY, ELIZABETH DAWN (CNA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DAWN
Last Name:PETTRY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 KLAUS ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-5834
Mailing Address - Country:US
Mailing Address - Phone:301-923-9314
Mailing Address - Fax:
Practice Address - Street 1:130 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2648
Practice Address - Country:US
Practice Address - Phone:304-929-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant