Healthcare Provider Details

I. General information

NPI: 1740728823
Provider Name (Legal Business Name): JULIE PETTIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 INDUSTRIAL BLVD
DUBLIN GA
31021-2981
US

IV. Provider business mailing address

3489 NEW BUCKEYE RD
WRIGHTSVILLE GA
31096-3770
US

V. Phone/Fax

Practice location:
  • Phone: 478-274-3865
  • Fax:
Mailing address:
  • Phone: 478-609-4269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04170449
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License NumberRN190687
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: