Healthcare Provider Details

I. General information

NPI: 1275647471
Provider Name (Legal Business Name): CARRIE LEIGH PETTEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 N SMITH AVENUE 302 CHILDRENS PRIMARY CLINIC STPL
ST. PAUL MN
55102
US

IV. Provider business mailing address

2910 CENTRE POINTE DR 35-121A CHILDRENS HEALTH CARE
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6789
  • Fax: 651-220-6807
Mailing address:
  • Phone: 651-855-2327
  • Fax: 651-855-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48509
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: