Provider Demographics
NPI:1790748168
Name:PETTY, MELISSA JANE (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:PETTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7029 CAMINO ROJO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3533
Mailing Address - Country:US
Mailing Address - Phone:254-760-3832
Mailing Address - Fax:
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-661-9230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03454363LN0000X
TXAP103226363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX500008494OtherRR/MEDICARE
TX0292880-02Medicaid
TX82N617OtherBLUE SHIELD
TX82N617OtherBLUE SHIELD
TX0292880-02Medicaid