Healthcare Provider Details

I. General information

NPI: 1841437787
Provider Name (Legal Business Name): CYNTHIA LOUISE PETTY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UIC, IJR, 1747 WEST ROOSEVELT ROAD, M/C 747 CU 113
CHICAGO IL
60608
US

IV. Provider business mailing address

UIC, IJR, 1747 WEST ROOSEVELT ROAD, M/C 747 CU 113
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-1136
  • Fax: 312-413-4459
Mailing address:
  • Phone: 312-413-1136
  • Fax: 312-413-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number209000709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: