Provider Demographics
NPI:1780889626
Name:PETTY, JOANN F (APN CNS)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:F
Last Name:PETTY
Suffix:
Gender:F
Credentials:APN CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 WEAVER PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3269
Mailing Address - Country:US
Mailing Address - Phone:630-352-5300
Mailing Address - Fax:630-352-5499
Practice Address - Street 1:4405 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-352-5300
Practice Address - Fax:630-352-5499
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2013-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004957364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147075OtherMEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)
IL206147OtherMEDICARE PTAN (GROUP)
ILP01013439OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)