Provider Demographics
NPI:1134602907
Name:PETTY, CRAIG MICHAEL (LPN)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:MICHAEL
Last Name:PETTY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 W JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:GLEN GARDNER
Mailing Address - State:NJ
Mailing Address - Zip Code:08826-6422
Mailing Address - Country:US
Mailing Address - Phone:908-386-8623
Mailing Address - Fax:
Practice Address - Street 1:43 JOHN ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-4237
Practice Address - Country:US
Practice Address - Phone:973-631-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07106000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse