Healthcare Provider Details

I. General information

NPI: 1093213738
Provider Name (Legal Business Name): KIMYATA LATRICE PETTAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 ASHLAND AVE
TOLEDO OH
43620-1703
US

IV. Provider business mailing address

2005 ASHLAND AVE
TOLEDO OH
43620-1703
US

V. Phone/Fax

Practice location:
  • Phone: 419-841-7701
  • Fax:
Mailing address:
  • Phone: 419-255-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN.446147
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.446147
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: