Provider Demographics
NPI:1053192641
Name:PETTRY, KEYANA
Entity type:Individual
Prefix:
First Name:KEYANA
Middle Name:
Last Name:PETTRY
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 1:74 CAINS RUN
Mailing Address - Street 2:
Mailing Address - City:REEDY
Mailing Address - State:WV
Mailing Address - Zip Code:25270-9340
Mailing Address - Country:US
Mailing Address - Phone:304-384-1706
Mailing Address - Fax:
Practice Address - Street 1:74 CAINS RUN
Practice Address - Street 2:
Practice Address - City:REEDY
Practice Address - State:WV
Practice Address - Zip Code:25270-9340
Practice Address - Country:US
Practice Address - Phone:304-384-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant