1275805905 NPI number — MRS. MELISSA CHRISTIE PETTY OTR/L

Table of content: MRS. MELISSA CHRISTIE PETTY OTR/L (NPI 1275805905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275805905 NPI number — MRS. MELISSA CHRISTIE PETTY OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTY
Provider First Name:
MELISSA
Provider Middle Name:
CHRISTIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETTY
Provider Other First Name:
MELISSA
Provider Other Middle Name:
CHRISTIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1275805905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 ICHORD AVE
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
WAYNESVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65583-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-881-1418
Provider Business Mailing Address Fax Number:
573-774-2487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 ICHORD AVE
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
WAYNESVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65583-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-881-1418
Provider Business Practice Location Address Fax Number:
573-774-2487
Provider Enumeration Date:
01/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  003468 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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