Provider Demographics
NPI:1861239352
Name:PETTWAY, SHANDRA R
Entity type:Individual
Prefix:MRS
First Name:SHANDRA
Middle Name:R
Last Name:PETTWAY
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 1:1709 LIBERTY ST N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-8002
Mailing Address - Country:US
Mailing Address - Phone:734-210-2507
Mailing Address - Fax:
Practice Address - Street 1:1709 LIBERTY ST N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-8002
Practice Address - Country:US
Practice Address - Phone:734-210-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health