Provider Demographics
NPI:1922435783
Name:PETTY, CHERYL ANN (BA, RSST, QIDP)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:ANN
Last Name:PETTY
Suffix:
Gender:F
Credentials:BA, RSST, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TOWNER
Mailing Address - Street 2:P.O BOX 915
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-544-3000
Mailing Address - Fax:734-544-6732
Practice Address - Street 1:2140 E. ELLSWORTH RD.
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108
Practice Address - Country:US
Practice Address - Phone:734-222-3592
Practice Address - Fax:734-222-3461
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085519172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker