Healthcare Provider Details

I. General information

NPI: 1184532301
Provider Name (Legal Business Name): CONNETTIA PEMBERTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2792 JORDAN AVE
MACON GA
31217-4918
US

IV. Provider business mailing address

2792 JORDAN AVE
MACON GA
31217-4918
US

V. Phone/Fax

Practice location:
  • Phone: 404-852-9790
  • Fax:
Mailing address:
  • Phone: 404-852-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number045318498
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: