Provider Demographics
NPI:1578968772
Name:PETTY, FORREST
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 E SILVER SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-6409
Mailing Address - Country:US
Mailing Address - Phone:352-694-5003
Mailing Address - Fax:352-694-6003
Practice Address - Street 1:3223 E SILVER SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6409
Practice Address - Country:US
Practice Address - Phone:352-694-5003
Practice Address - Fax:352-694-6003
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4967237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist