Provider Demographics
NPI:1801450010
Name:PETTIES, CHRISTINA MARIE DENISE
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE DENISE
Last Name:PETTIES
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 1:12730 WHITTINGTON DR APT 902
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-4752
Mailing Address - Country:US
Mailing Address - Phone:713-909-6192
Mailing Address - Fax:
Practice Address - Street 1:12730 WHITTINGTON DR APT 902
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-4752
Practice Address - Country:US
Practice Address - Phone:713-909-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37185608172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver