Provider Demographics
NPI:1942606546
Name:PETTY, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TAMMY
Other - Middle Name:SUE
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:113 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MC ARTHUR
Mailing Address - State:OH
Mailing Address - Zip Code:45651-1168
Mailing Address - Country:US
Mailing Address - Phone:910-352-9078
Mailing Address - Fax:
Practice Address - Street 1:113 ROSEMONT AVE
Practice Address - Street 2:
Practice Address - City:MC ARTHUR
Practice Address - State:OH
Practice Address - Zip Code:45651-1168
Practice Address - Country:US
Practice Address - Phone:910-352-9078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-08
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH095130164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse