Provider Demographics
NPI:1063708691
Name:FETTY, KRISTY RENEE (COTA)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:RENEE
Last Name:FETTY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:KRISTY
Other - Middle Name:RENEE
Other - Last Name:FETTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:6351 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2676
Mailing Address - Country:US
Mailing Address - Phone:814-314-1637
Mailing Address - Fax:814-838-0583
Practice Address - Street 1:6351 W LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-2676
Practice Address - Country:US
Practice Address - Phone:814-314-1637
Practice Address - Fax:814-838-0583
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP005890224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant