Provider Demographics
NPI:1265413447
Name:PETTREY, JOHANNA CHRISTINE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:CHRISTINE
Last Name:PETTREY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4154
Mailing Address - Country:US
Mailing Address - Phone:575-935-9000
Mailing Address - Fax:575-935-1002
Practice Address - Street 1:1515 W FIR ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5703
Practice Address - Country:US
Practice Address - Phone:575-356-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR47083363LF0000X
VA0001144582363LF0000X
NMCNP01151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG7157Medicaid
P44094Medicare UPIN