Provider Demographics
NPI:1114204419
Name:PETTY, MARIA C (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:C
Last Name:PETTY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35000 KAISER CT
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3382
Mailing Address - Country:US
Mailing Address - Phone:440-269-4600
Mailing Address - Fax:216-229-6017
Practice Address - Street 1:35000 KAISER CT
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3382
Practice Address - Country:US
Practice Address - Phone:440-269-4600
Practice Address - Fax:216-229-6017
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004979363LG0600X
OHNP020610363LP2300X
MARN2290435363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology