Provider Demographics
NPI:1407078959
Name:PETTY, JOAN ELLEN (NPP)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:ELLEN
Last Name:PETTY
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CHRISTOPHER STREET #2B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014
Mailing Address - Country:US
Mailing Address - Phone:212-769-7965
Mailing Address - Fax:212-203-7363
Practice Address - Street 1:10 CHRISTOPHER STREET #2B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014
Practice Address - Country:US
Practice Address - Phone:212-769-7965
Practice Address - Fax:212-203-7363
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF40028363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health