Provider Demographics
NPI:1083811871
Name:PETTY, DORIS JEAN (RN)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:JEAN
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 1:2021 4TH AVE NW TRLR 77
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2529
Mailing Address - Country:US
Mailing Address - Phone:580-276-3323
Mailing Address - Fax:580-276-3324
Practice Address - Street 1:200 WANDA
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OK
Practice Address - Zip Code:73448
Practice Address - Country:US
Practice Address - Phone:580-276-3323
Practice Address - Fax:580-276-3324
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0027558163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse