Provider Demographics
NPI:1457668030
Name:PETRY, TANYA RAEANN (RN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:RAEANN
Last Name:PETRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9704 MERIMBULA ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-7169
Mailing Address - Country:US
Mailing Address - Phone:303-683-6926
Mailing Address - Fax:
Practice Address - Street 1:9704 MERIMBULA ST
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80130-7169
Practice Address - Country:US
Practice Address - Phone:303-683-6926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19572163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse