Healthcare Provider Details

I. General information

NPI: 1891073763
Provider Name (Legal Business Name): ANTOINETTE PETA-GAY LEE-GREGORY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT MOORE GA
31905-2102
US

IV. Provider business mailing address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-0493
  • Fax:
Mailing address:
  • Phone: 678-312-3294
  • Fax: 678-312-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPRN-CNM185722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: