Provider Demographics
NPI:1932509833
Name:PETTY, BLANCHE FOSHEE' (APRN)
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:FOSHEE'
Last Name:PETTY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8061 CREEKWOOD CIR W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5431
Mailing Address - Country:US
Mailing Address - Phone:901-649-3113
Mailing Address - Fax:
Practice Address - Street 1:730 GOODMAN RD E STE B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-649-6087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18870363LX0001X
MS109301363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology