Provider Demographics
NPI:1831077767
Name:PETTIFORD, CHANTE DOMINIQUE (DPT)
Entity type:Individual
Prefix:
First Name:CHANTE
Middle Name:DOMINIQUE
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N MAIN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-8573
Mailing Address - Country:US
Mailing Address - Phone:919-232-5020
Mailing Address - Fax:
Practice Address - Street 1:2400 N MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-8573
Practice Address - Country:US
Practice Address - Phone:919-232-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP24409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist