=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477479855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE LEE PETTEYS CRPA-P
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2026
-----------------------------------------------------
Last Update Date | 06/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 1ST AVE
-----------------------------------------------------
City | GLOVERSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12078-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-725-5646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 LOOMIS ST APT 2
-----------------------------------------------------
City | LITTLE FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13365-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | 5528
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------