Provider Demographics
NPI:1902249675
Name:PETTEYS, MONIQUE DIANE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:DIANE
Last Name:PETTEYS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:LONG CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29658-2105
Mailing Address - Country:US
Mailing Address - Phone:706-982-4434
Mailing Address - Fax:
Practice Address - Street 1:189 BO JAMES ST STE 105
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-6199
Practice Address - Country:US
Practice Address - Phone:706-782-0016
Practice Address - Fax:706-782-0180
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily