Basic Information
| Provider Information | |||||||||
| NPI: | 1376043174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTWAY | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 AMBER LN | ||||||||
| Address2: | |||||||||
| City: | HARVEST | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357499339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563377747 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4040 MEMORIAL PKWY SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358024364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565331970 | ||||||||
| FaxNumber: | 2567056477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 02/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 2-065334 | AL | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 330000014 | 05 | AL | MEDICAID |