Healthcare Provider Details

I. General information

NPI: 1043541725
Provider Name (Legal Business Name): JANINE NICOLE PETTIFORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 NORTH JEFF DAVIS DR
FAYETTEVILLE GA
30214
US

IV. Provider business mailing address

33 UPPER RIVERDALE ROAD SW SUITE 112
FAYETTEVILLE GA
30214-1627
US

V. Phone/Fax

Practice location:
  • Phone: 770-461-1337
  • Fax: 770-461-0922
Mailing address:
  • Phone: 770-996-3190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10023659
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2010013505
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number072414
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: