Provider Demographics
NPI:1033610043
Name:PETTY, MARTHA ALICE (RN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ALICE
Last Name:PETTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 CYPRESS HAMMOCK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-8920
Mailing Address - Country:US
Mailing Address - Phone:317-809-9429
Mailing Address - Fax:
Practice Address - Street 1:600 B ST STE 1570
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4560
Practice Address - Country:US
Practice Address - Phone:619-615-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95147003163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty