Provider Demographics
NPI:1801302690
Name:PETTY, MICHELLE SUZANNE (LPN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUZANNE
Last Name:PETTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 S IRELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2220
Mailing Address - Country:US
Mailing Address - Phone:863-677-4472
Mailing Address - Fax:
Practice Address - Street 1:95 S IRELAND BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-2220
Practice Address - Country:US
Practice Address - Phone:863-677-4472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-16
Last Update Date:2017-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH167093164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty