=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699568212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRISTINA MIHAELA PETTY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1378 NW 124TH ST
-----------------------------------------------------
City | CLIVE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50325-8151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-226-9119
-----------------------------------------------------
Fax | 515-226-8123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2416 LOCUST ST
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50265-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-339-2167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F03250482
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------