Healthcare Provider Details

I. General information

NPI: 1992357644
Provider Name (Legal Business Name): NIKKI PETTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 SHILOH RD STE 100
ALPHARETTA GA
30005-1645
US

IV. Provider business mailing address

6505 SHILOH RD STE 100
ALPHARETTA GA
30005-1645
US

V. Phone/Fax

Practice location:
  • Phone: 678-648-7644
  • Fax:
Mailing address:
  • Phone: 678-648-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-89472
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: