Provider Demographics
NPI:1134404957
Name:PETTY, DAWN LYNETTE (NP)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:LYNETTE
Last Name:PETTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:DAWN
Other - Middle Name:LYNETTE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:20 NE SAINT LUKES BOULEVARD
Mailing Address - Street 2:SUITE #350
Mailing Address - City:LEE'S SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6007
Mailing Address - Country:US
Mailing Address - Phone:816-524-5333
Mailing Address - Fax:816-524-4325
Practice Address - Street 1:20 NE SAINT LUKES BOULEVARD
Practice Address - Street 2:SUITE #350
Practice Address - City:LEE'S SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6007
Practice Address - Country:US
Practice Address - Phone:816-524-5333
Practice Address - Fax:816-524-4325
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75468-111363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner