Provider Demographics
NPI:1518513118
Name:PETTY, LISA (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 411
Mailing Address - Street 2:
Mailing Address - City:MONTROSS
Mailing Address - State:VA
Mailing Address - Zip Code:22520
Mailing Address - Country:US
Mailing Address - Phone:443-966-5191
Mailing Address - Fax:
Practice Address - Street 1:618 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-11
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine