Healthcare Provider Details

I. General information

NPI: 1881375780
Provider Name (Legal Business Name): TINESHA SHANTA PETTIWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E MEDICAL CENTER BLVD # 100
WEBSTER TX
77598-4376
US

IV. Provider business mailing address

12700 STAFFORD RD APT 1321
STAFFORD TX
77477-3576
US

V. Phone/Fax

Practice location:
  • Phone: 346-800-6001
  • Fax:
Mailing address:
  • Phone: 205-401-7386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1129705
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1129705
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1129705
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: