Provider Demographics
NPI:1841437787
Name:PETTY, CYNTHIA LOUISE (APN)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LOUISE
Last Name:PETTY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UIC, IJR, 1747 WEST ROOSEVELT ROAD, M/C 747
Mailing Address - Street 2:CU 113
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608
Mailing Address - Country:US
Mailing Address - Phone:312-413-1136
Mailing Address - Fax:312-413-4459
Practice Address - Street 1:UIC, IJR, 1747 WEST ROOSEVELT ROAD, M/C 747
Practice Address - Street 2:CU 113
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:312-413-1136
Practice Address - Fax:312-413-4459
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000709163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS95670Medicare UPIN