Provider Demographics
NPI:1235681156
Name:PETTITT, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PETTITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1776
Mailing Address - Street 2:
Mailing Address - City:CLAYPOOL
Mailing Address - State:AZ
Mailing Address - Zip Code:85532
Mailing Address - Country:US
Mailing Address - Phone:520-904-8815
Mailing Address - Fax:
Practice Address - Street 1:138 S. BROAD STREET
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501
Practice Address - Country:US
Practice Address - Phone:928-425-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16-1574175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath