Healthcare Provider Details

I. General information

NPI: 1184264400
Provider Name (Legal Business Name): CORTNEY PETTY WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 TAYLOR RD
MONTGOMERY AL
36117-3513
US

IV. Provider business mailing address

467 SELLARS RD
MONTGOMERY AL
36116-7502
US

V. Phone/Fax

Practice location:
  • Phone: 334-747-8443
  • Fax:
Mailing address:
  • Phone: 334-201-4463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1-148576
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-148576
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: