Provider Demographics
NPI:1164008967
Name:PETTY, AMBRIA J (NP)
Entity Type:Individual
Prefix:
First Name:AMBRIA
Middle Name:J
Last Name:PETTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22742 MIDLAND DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-3553
Mailing Address - Country:US
Mailing Address - Phone:913-441-2293
Mailing Address - Fax:
Practice Address - Street 1:19001 E 48TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6964
Practice Address - Country:US
Practice Address - Phone:816-251-5100
Practice Address - Fax:816-795-0144
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79703-032363LF0000X
MO2020032346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily