Healthcare Provider Details

I. General information

NPI: 1255951216
Provider Name (Legal Business Name): MICHAEL GLENN PETTY RN, ACNS-BC, CCNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HARVARD ST SE
MINNEAPOLIS MN
55455-0363
US

IV. Provider business mailing address

7615 XERXES AVE S
RICHFIELD MN
55423-3546
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-5607
  • Fax: 612-273-9966
Mailing address:
  • Phone: 612-273-5607
  • Fax: 612-273-9966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number095570
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License Number71
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number71
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: