Provider Demographics
NPI:1780998674
Name:PETTYE, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:PETTYE
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 1:3618 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2126
Mailing Address - Country:US
Mailing Address - Phone:708-228-0999
Mailing Address - Fax:
Practice Address - Street 1:3618 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2126
Practice Address - Country:US
Practice Address - Phone:708-228-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043071327164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse