Provider Demographics
NPI:1699316778
Name:PETTIFORD, KAREN (RN)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:NEVELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NA
Mailing Address - Street 1:343 MAIN ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8712
Mailing Address - Country:US
Mailing Address - Phone:505-869-2679
Mailing Address - Fax:
Practice Address - Street 1:343 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8712
Practice Address - Country:US
Practice Address - Phone:505-869-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR61844163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool