Healthcare Provider Details

I. General information

NPI: 1376322172
Provider Name (Legal Business Name): TERI KAYE PETTAWAY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERI KAYE MONTGOMERY

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOE FRANK HARRIS PKWY SE
CARTERSVILLE GA
30120-2129
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-2142
  • Fax:
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number28655
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN339928
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: