Provider Demographics
NPI:1487118782
Name:PETRY, KRISTA LEIGH (FNP)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEIGH
Last Name:PETRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:LEIGH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4720 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-9772
Mailing Address - Country:US
Mailing Address - Phone:716-456-2149
Mailing Address - Fax:
Practice Address - Street 1:890 E 2ND ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-3824
Practice Address - Country:US
Practice Address - Phone:716-661-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343971363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily