Provider Demographics
NPI:1154133346
Name:PETTIGREW, CANDICE LYN
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:LYN
Last Name:PETTIGREW
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 1:621 S TABOR AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5663
Mailing Address - Country:US
Mailing Address - Phone:308-233-1156
Mailing Address - Fax:
Practice Address - Street 1:621 S TABOR AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5663
Practice Address - Country:US
Practice Address - Phone:308-233-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant