Individual
SHALITA PETTWAY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
7229 PINE LAKES BLVD, PORT ST LUCIE, FL 34952
(772) 214-6911
Mailing address
PO BOX 8532, HOBE SOUND, FL 33455
(772) 214-6911
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
171M000000X
MEDICARE & MEDICAID SERVICES CMS
FL
Enumeration date
09/25/2014
Last updated
09/25/2014
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