Provider Demographics
NPI:1124237359
Name:PETTICREW, LYRA (MED)
Entity type:Individual
Prefix:
First Name:LYRA
Middle Name:
Last Name:PETTICREW
Suffix:
Gender:F
Credentials:MED
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 2127
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929-2127
Mailing Address - Country:US
Mailing Address - Phone:907-874-3375
Mailing Address - Fax:907-874-3339
Practice Address - Street 1:110 LYNCH ST.
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929-1231
Practice Address - Country:US
Practice Address - Phone:907-874-3375
Practice Address - Fax:907-874-3339
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM 1085Medicaid