Provider Demographics
NPI:1013290196
Name:PETTY, LAURA (DPH)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 N HENNY RD
Mailing Address - Street 2:
Mailing Address - City:JONES
Mailing Address - State:OK
Mailing Address - Zip Code:73049-6149
Mailing Address - Country:US
Mailing Address - Phone:405-399-3474
Mailing Address - Fax:
Practice Address - Street 1:201 NW 63RD ST STE 390
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-8210
Practice Address - Country:US
Practice Address - Phone:405-842-8492
Practice Address - Fax:405-842-8012
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist