Healthcare Provider Details

I. General information

NPI: 1750734752
Provider Name (Legal Business Name): DEMETRIA PETTAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 SPRING HILL AVE
MOBILE AL
36607-2303
US

IV. Provider business mailing address

1903 SPRING HILL AVE
MOBILE AL
36607-2303
US

V. Phone/Fax

Practice location:
  • Phone: 251-295-5110
  • Fax: 251-545-4963
Mailing address:
  • Phone: 251-295-5110
  • Fax: 251-545-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: