Provider Demographics
NPI:1568472918
Name:PETTY, BRENDA KAY (DOM)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAY
Last Name:PETTY
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 GOODRICH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1139
Mailing Address - Country:US
Mailing Address - Phone:505-883-4831
Mailing Address - Fax:505-237-8657
Practice Address - Street 1:9809 CANDELARIA RD NE
Practice Address - Street 2:SUITE 2B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1458
Practice Address - Country:US
Practice Address - Phone:505-883-4831
Practice Address - Fax:505-237-8657
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM857171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist