Healthcare Provider Details

I. General information

NPI: 1922435783
Provider Name (Legal Business Name): CHERYL ANN PETTY BA, RSST, QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 E. ELLSWORTH RD.
ANN ARBOR MI
48108
US

IV. Provider business mailing address

555 TOWNER P.O BOX 915
YPSILANTI MI
48198-5752
US

V. Phone/Fax

Practice location:
  • Phone: 734-222-3592
  • Fax: 734-222-3461
Mailing address:
  • Phone: 734-544-3000
  • Fax: 734-544-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number6803085519
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: