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General NPI Number Information
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NPI Number | 1386225712
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Entity Type | Individual
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Provider Name | PETTY TINEO
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Gender | Female
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Dates
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Enumeration Date | 04/17/2021
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Last Update Date | 07/22/2022
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Provider Practice Location Address
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Address Line | 3959 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10032-1559
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Country | US
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Telephone | 551-795-2266
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Fax |
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Provider Business Mailing Address
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Address Line | 1 NORMAL AVE
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City | MONTCLAIR
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State | NJ
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Zip | 07043-1624
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Country | US
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Telephone | 551-795-2266
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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