MEDICARE: MYRA C PETTIGREW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1881153369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRA C PETTIGREW

Provider Business Mailing Address
First Line	:	2541 NW 21ST ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-3201
Country	:	US
Telephone Number	:	405-977-2369
Fax Number	:

Provider Business Practice Location Address
First Line	:	2541 NW 21ST ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-3201
Country	:	US
Telephone Number	:	405-977-2369
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2019
Last Update Date	:	03/14/2019

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Directions to “ MYRA C PETTIGREW ” Practice Location

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