Healthcare Provider Details

I. General information

NPI: 1841422359
Provider Name (Legal Business Name): GLENDA V PETTAWAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GLENDA V WRIGHT

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N COLEMAN ST
SWAINSBORO GA
30401-3530
US

IV. Provider business mailing address

215 N COLEMAN ST
SWAINSBORO GA
30401-3530
US

V. Phone/Fax

Practice location:
  • Phone: 478-237-2638
  • Fax: 478-237-9138
Mailing address:
  • Phone: 478-237-2638
  • Fax: 478-237-9138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number062456
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: