Healthcare Provider Details

I. General information

NPI: 1902331598
Provider Name (Legal Business Name): RYAN PETTY DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6379 SILVER LAKE RD
LINDEN MI
48451-8706
US

IV. Provider business mailing address

3495 S CENTER RD
BURTON MI
48519-1455
US

V. Phone/Fax

Practice location:
  • Phone: 810-735-7847
  • Fax: 810-735-7159
Mailing address:
  • Phone: 810-424-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704289644
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: