Healthcare Provider Details

I. General information

NPI: 1033610043
Provider Name (Legal Business Name): MARTHA ALICE PETTY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 B ST STE 1570
SAN DIEGO CA
92101-4560
US

IV. Provider business mailing address

4955 CYPRESS HAMMOCK DR
SAINT CLOUD FL
34771-8920
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0439
  • Fax:
Mailing address:
  • Phone: 317-809-9429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN95147003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: