Provider Demographics
NPI:1174090153
Name:PETTY, LANCE MICHAEL
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:MICHAEL
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18158 WOODSDALE CT
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-3651
Mailing Address - Country:US
Mailing Address - Phone:281-601-5565
Mailing Address - Fax:
Practice Address - Street 1:701 EDGEWATER DR STE 300
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-6242
Practice Address - Country:US
Practice Address - Phone:781-486-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345381163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse