Healthcare Provider Details

I. General information

NPI: 1174090153
Provider Name (Legal Business Name): LANCE MICHAEL PETTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 EDGEWATER DR STE 300
WAKEFIELD MA
01880-6242
US

IV. Provider business mailing address

18158 WOODSDALE CT
PORTER TX
77365-3651
US

V. Phone/Fax

Practice location:
  • Phone: 781-486-4116
  • Fax:
Mailing address:
  • Phone: 281-601-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number345381
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: