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General NPI Number Information
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NPI Number | 1033610043
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Entity Type | Individual
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Provider Name | MARTHA ALICE PETTY RN
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Gender | Female
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Dates
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Enumeration Date | 02/24/2018
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Last Update Date | 02/24/2018
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Provider Practice Location Address
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Address Line | 600 B ST STE 1570
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City | SAN DIEGO
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State | CA
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Zip | 92101-4560
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Country | US
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Telephone | 619-615-0439
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Fax |
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Provider Business Mailing Address
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Address Line | 4955 CYPRESS HAMMOCK DR
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City | SAINT CLOUD
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State | FL
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Zip | 34771-8920
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Country | US
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Telephone | 317-809-9429
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | RN95147003
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License Number State | CA
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