Provider Demographics
NPI:1154873248
Name:PETTY, KAREN LEE
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LEE
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 1:4141 W NEZ PERCE ST
Mailing Address - Street 2:APT 324
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2959
Mailing Address - Country:US
Mailing Address - Phone:208-919-4861
Mailing Address - Fax:
Practice Address - Street 1:1220 MONTANA ST
Practice Address - Street 2:101
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1856
Practice Address - Country:US
Practice Address - Phone:208-934-5601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1626224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant