Healthcare Provider Details

I. General information

NPI: 1083196836
Provider Name (Legal Business Name): PETA-GAYE C PILOTE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 REGAL WAY E
MCDONOUGH GA
30253
US

IV. Provider business mailing address

319 REGAL WAY E
MCDONOUGH GA
30253-8248
US

V. Phone/Fax

Practice location:
  • Phone: 678-559-2488
  • Fax:
Mailing address:
  • Phone: 678-559-2488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberPCH007436
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN249535
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: