Provider Demographics
NPI:1598512758
Name:PETTIGREW, MARYLENA JUANNA
Entity type:Individual
Prefix:
First Name:MARYLENA
Middle Name:JUANNA
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 1:1289 FIRETHORNE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1184
Mailing Address - Country:US
Mailing Address - Phone:513-919-3972
Mailing Address - Fax:
Practice Address - Street 1:1289 FIRETHORNE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1184
Practice Address - Country:US
Practice Address - Phone:513-919-3972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401593141213376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide