Healthcare Provider Details

I. General information

NPI: 1902230592
Provider Name (Legal Business Name): MICHELE BRITTANY PETTIGREW LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W. ING STREET
KINGSTON OH
45644-0584
US

IV. Provider business mailing address

PO BOX 584 53 WEST ING STREET
KINGSTON OH
45644-0584
US

V. Phone/Fax

Practice location:
  • Phone: 740-466-7116
  • Fax:
Mailing address:
  • Phone: 740-466-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number140107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: