Provider Demographics
NPI:1790597078
Name:PETTIFORD, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FALERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:32 LANDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-4803
Mailing Address - Country:US
Mailing Address - Phone:912-412-4509
Mailing Address - Fax:
Practice Address - Street 1:32 LANDWARD WAY
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-4803
Practice Address - Country:US
Practice Address - Phone:912-412-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant