Basic Information
| Provider Information | |||||||||
| NPI: | 1568199362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTWAY | ||||||||
| FirstName: | XHANE | ||||||||
| MiddleName: | ANGELIQUE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6218 SUMMER SIDE CIR | ||||||||
| Address2: | |||||||||
| City: | PINSON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351264430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2055782171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 DEAN DR | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056318709 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2022 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 5522 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.