Provider Demographics
NPI:1477622181
Name:PETTY, SUE ELLEN (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:ELLEN
Last Name:PETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445
Mailing Address - Country:US
Mailing Address - Phone:270-365-0320
Mailing Address - Fax:270-365-4150
Practice Address - Street 1:320 MICBETH DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-6332
Practice Address - Country:US
Practice Address - Phone:270-365-0320
Practice Address - Fax:270-365-4150
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34383208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64343833Medicaid
KY1838201Medicare ID - Type Unspecified
KY64343833Medicaid