Provider Demographics
NPI:1902198385
Name:PETTY, MELODY LYNN
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:LYNN
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:1700 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3301
Practice Address - Country:US
Practice Address - Phone:251-415-1343
Practice Address - Fax:251-415-1353
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33733208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program