Healthcare Provider Details

I. General information

NPI: 1265413447
Provider Name (Legal Business Name): JOHANNA CHRISTINE PETTREY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W FIR ST
PORTALES NM
88130-5703
US

IV. Provider business mailing address

912 W 21ST ST
CLOVIS NM
88101-4154
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-6695
  • Fax:
Mailing address:
  • Phone: 575-935-9000
  • Fax: 575-935-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR47083
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001144582
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: