Provider Demographics
NPI:1336774801
Name:PETMI, MICHELLE STEPHANIE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:STEPHANIE
Last Name:PETMI
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33584 GREEN PRAIRIE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-2668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33584 GREEN PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-2668
Practice Address - Country:US
Practice Address - Phone:646-642-3979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145527363LF0000X
TX2019075997363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health