Provider Demographics
NPI:1356711220
Name:PETTY, SHEKODA M (STNA)
Entity type:Individual
Prefix:
First Name:SHEKODA
Middle Name:M
Last Name:PETTY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26217 CAMBRIDGE LN
Mailing Address - Street 2:APT 301
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-6106
Mailing Address - Country:US
Mailing Address - Phone:567-219-9803
Mailing Address - Fax:
Practice Address - Street 1:26217 CAMBRIDGE LN
Practice Address - Street 2:APT 301
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-6106
Practice Address - Country:US
Practice Address - Phone:567-219-9803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-04
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401750070515376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide