MEDICARE: LADENIA KIONA PETTWAY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LPN.144710-MEDS-IV	OH
2	163W00000X	Registered Nurse	RN.532828	OH

General Provider Information

NPI Number	:	1831600261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LADENIA KIONA PETTWAY RN

Provider Business Mailing Address
First Line	:	1402 KENOVA AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-3111
Country	:	US
Telephone Number	:	513-356-3430
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 KENOVA AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-3111
Country	:	US
Telephone Number	:	513-356-3430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2017
Last Update Date	:	03/20/2024

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