Provider Demographics
NPI:1669092888
Name:PETTY, REGINA D (MSN, APRN, PMHNP)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:D
Last Name:PETTY
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15462 SPOTTED STALLION TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32234-2398
Mailing Address - Country:US
Mailing Address - Phone:352-328-0571
Mailing Address - Fax:
Practice Address - Street 1:15462 SPOTTED STALLION TRL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32234-2398
Practice Address - Country:US
Practice Address - Phone:352-328-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9339167163W00000X
FLAPRN11018524363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse