Healthcare Provider Details

I. General information

NPI: 1710409610
Provider Name (Legal Business Name): SHONTE'E ELAINE PETTUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14660 OXNARD ST
VAN NUYS CA
91411-3119
US

IV. Provider business mailing address

44200 KINGTREE AVE UNIT 2
LANCASTER CA
93534-4115
US

V. Phone/Fax

Practice location:
  • Phone: 818-901-4836
  • Fax: 818-376-0044
Mailing address:
  • Phone: 661-208-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: