Healthcare Provider Details

I. General information

NPI: 1033846878
Provider Name (Legal Business Name): CANIVORY PETTIWAY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 CENTRAL AVE
ALBANY NY
12206-1513
US

IV. Provider business mailing address

114 UNIVERSITY AVE
ROCHESTER NY
14605-2929
US

V. Phone/Fax

Practice location:
  • Phone: 518-434-5678
  • Fax:
Mailing address:
  • Phone: 585-371-8373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349914
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: