Provider Demographics
NPI:1689450520
Name:PETTY, POYU BAMBY (FNP)
Entity Type:Individual
Prefix:
First Name:POYU
Middle Name:BAMBY
Last Name:PETTY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:POYU
Other - Middle Name:BAMBY
Other - Last Name:CHAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:216 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-9042
Mailing Address - Fax:
Practice Address - Street 1:216 OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3115
Practice Address - Country:US
Practice Address - Phone:625-534-9042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879298163WH1000X
MS906331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH1000XNursing Service ProvidersRegistered NurseHospice