Healthcare Provider Details

I. General information

NPI: 1326829730
Provider Name (Legal Business Name): LORINA PETTWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 PARK AVE
BRIDGEPORT CT
06604-1049
US

IV. Provider business mailing address

594 BIRMINGHAM ST
BRIDGEPORT CT
06606-3348
US

V. Phone/Fax

Practice location:
  • Phone: 203-396-1129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number10.174564
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: