Kristofer Kedar Pettway

Primary specialty

Prevention ProfessionalTaxonomy code 405300000X

License

19393832 Issued in NY

Practice address

411 S Normade Ave Apt 732
Los Angeles, CA 90020-3396

Phone

(516) 919-0061

NPI assigned

Jul 23, 2022

Last updated

Jul 23, 2022By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1658534400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658534400000",
    "number": "1427783315",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "411 S NORMADE AVE APT 732",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900203396",
            "telephone_number": "516-919-0615"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "411 S NORMADE AVE APT 732",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900203396",
            "telephone_number": "516-919-0061"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETTWAY",
        "first_name": "KRISTOFER",
        "middle_name": "KEDAR",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-07-23",
        "last_updated": "2022-07-23",
        "certification_date": "2022-07-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "405300000X",
            "taxonomy_group": "",
            "desc": "Prevention Professional",
            "state": "NY",
            "license": "19393832",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Gayane Elizabeth Pettibone
• Angela Pettinelli
• Lisa Jo Pettinelli, RRT, RN
• Alexander Pettis, PTA
• Jerell Akeem Pettway
• Tyree Pettway
• Jasmine Petty-Davidson
• Noelle Caron Petty-Marchand
• Ernestine R Petty, M.D.
• Jadah Marie Sun Petty, PH.D.

• Prevention Professional in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Prevention Professional in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.