Healthcare Provider Details

I. General information

NPI: 1346158821
Provider Name (Legal Business Name): SHAREE NYCOLE PETTIFORD OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 COUNTRY GATE DR
NEW WHITELAND IN
46184-8016
US

IV. Provider business mailing address

5718 ENSENADA AVE
INDIANAPOLIS IN
46237-2212
US

V. Phone/Fax

Practice location:
  • Phone: 317-204-3736
  • Fax:
Mailing address:
  • Phone: 317-204-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31005249A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: