Provider Demographics
NPI:1144465659
Name:PETTIT, REBECCA LEE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13116 226TH ST E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-7897
Mailing Address - Country:US
Mailing Address - Phone:253-208-7382
Mailing Address - Fax:
Practice Address - Street 1:2323 JENSEN ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3605
Practice Address - Country:US
Practice Address - Phone:360-825-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60047356225200000X
OR8570314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty