Individual
KELLY RAE PETTIGREW
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OPTICIAN LICENSE FL
Contact information
Practice address
505 NORTH MUNDO, DULCE, NM 87528
(575) 759-3291
Mailing address
PO BOX 187, DULCE, NM 87528-0187
(575) 759-3291
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
DO5748
FL
Other
Enumeration date
06/29/2018
Last updated
06/29/2018
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