Healthcare Provider Details

I. General information

NPI: 1568472918
Provider Name (Legal Business Name): BRENDA KAY PETTY DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

9809 CANDELARIA RD NE SUITE 2B
ALBUQUERQUE NM
87112-1458
US

IV. Provider business mailing address

4816 GOODRICH AVE NE
ALBUQUERQUE NM
87110-1139
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-4831
  • Fax: 505-237-8657
Mailing address:
  • Phone: 505-883-4831
  • Fax: 505-237-8657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number857
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: