Provider Demographics
NPI:1013341627
Name:PETTY, ELIZABETH G
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:G
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 1:2401 E BLACKSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-3206
Mailing Address - Country:US
Mailing Address - Phone:864-576-6151
Mailing Address - Fax:864-595-2429
Practice Address - Street 1:2401 E BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:ROEBUCK
Practice Address - State:SC
Practice Address - Zip Code:29376-3206
Practice Address - Country:US
Practice Address - Phone:864-576-6151
Practice Address - Fax:864-595-2429
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP13063164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse