Provider Demographics
NPI:1366622185
Name:PETTY, CLARE (APRN, BC)
Entity type:Individual
Prefix:
First Name:CLARE
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 COLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-1323
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:300 E 8TH ST STE 121
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3379
Practice Address - Country:US
Practice Address - Phone:740-374-7464
Practice Address - Fax:740-374-1562
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV46395363LF0000X
OHCOA.10940.NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011172Medicaid
OH2953399Medicaid
OH000000633181OtherANTHEM
WV3810011172Medicaid
OH2953399Medicaid
OH6038431Medicare PIN
WV3810011172Medicaid
OH2953399Medicaid