Healthcare Provider Details

I. General information

NPI: 1790748168
Provider Name (Legal Business Name): MELISSA JANE PETTY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

7029 CAMINO ROJO
SANTA FE NM
87507-3533
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-9230
  • Fax:
Mailing address:
  • Phone: 254-760-3832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberCNP-03454
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: