Provider Demographics
NPI:1275647471
Name:PETTEY, CARRIE LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEIGH
Last Name:PETTEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2910 CENTRE POINTE DR 35-121A
Mailing Address - Street 2:CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2327
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:347 N SMITH AVENUE 302
Practice Address - Street 2:CHILDRENS PRIMARY CLINIC STPL
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6789
Practice Address - Fax:651-220-6807
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN48509208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics