Provider Demographics
NPI:1205202207
Name:PETTY, TAMIKA SHAWNTRICE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TAMIKA
Middle Name:SHAWNTRICE
Last Name:PETTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TAMIKA
Other - Middle Name:SHAWNTRICE
Other - Last Name:NEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:189 BRUNSWICK BLVD
Mailing Address - Street 2:2
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1622
Mailing Address - Country:US
Mailing Address - Phone:716-247-1481
Mailing Address - Fax:
Practice Address - Street 1:189 BRUNSWICK BLVD
Practice Address - Street 2:2
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1622
Practice Address - Country:US
Practice Address - Phone:716-247-1481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280729164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse