=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083811871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DORIS JEAN PETTY RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 WANDA
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-276-3323
-----------------------------------------------------
Fax | 580-276-3324
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 4TH AVE NW TRLR 77
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-276-3323
-----------------------------------------------------
Fax | 580-276-3324
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R0027558
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------