Healthcare Provider Details

I. General information

NPI: 1114062882
Provider Name (Legal Business Name): NICOLE B PETCHENIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE YONA BAUMGARTEN MD

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4360 CHAMBLEE DUNWOODY RD SUITE 370
ATLANTA GA
30341-1049
US

IV. Provider business mailing address

4360 CHAMBLEE DUNWOODY RD SUITE 370
ATLANTA GA
30341-1049
US

V. Phone/Fax

Practice location:
  • Phone: 770-399-5055
  • Fax: 770-399-9638
Mailing address:
  • Phone: 770-399-5055
  • Fax: 770-399-9638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number063116
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: