Provider Demographics
NPI:1962121640
Name:PETTY, MAKENNA
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 SHEPHERD RD
Mailing Address - Street 2:
Mailing Address - City:LAWSON
Mailing Address - State:MO
Mailing Address - Zip Code:64062-9219
Mailing Address - Country:US
Mailing Address - Phone:816-522-5290
Mailing Address - Fax:
Practice Address - Street 1:201 N FOREST AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-2696
Practice Address - Country:US
Practice Address - Phone:816-521-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022032603225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist