Provider Demographics
NPI:1447784236
Name:PETTAWAY, THERESA (PCD,DONA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:PCD,DONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2430
Mailing Address - Country:US
Mailing Address - Phone:610-553-5481
Mailing Address - Fax:610-553-5482
Practice Address - Street 1:624 MASON AVE
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-2430
Practice Address - Country:US
Practice Address - Phone:610-553-5481
Practice Address - Fax:610-553-5482
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
PA18087374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA233089455Medicaid
PA1043794560002Medicaid