Provider Demographics
NPI:1992531479
Name:PETTIFORD, ROSHELLE DESHAWN
Entity type:Individual
Prefix:
First Name:ROSHELLE
Middle Name:DESHAWN
Last Name:PETTIFORD
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 1:19101 EVERGREEN RD APT 506
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2682
Mailing Address - Country:US
Mailing Address - Phone:313-918-6623
Mailing Address - Fax:
Practice Address - Street 1:19101 EVERGREEN RD APT 506
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2682
Practice Address - Country:US
Practice Address - Phone:313-918-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care