Healthcare Provider Details

I. General information

NPI: 1952758955
Provider Name (Legal Business Name): PETAGAYE ANTOINETTE PETERKIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 04/19/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 LYNBURN DR
TUCKER GA
30084-4485
US

IV. Provider business mailing address

4333 LYNBURN DR
TUCKER GA
30084-4485
US

V. Phone/Fax

Practice location:
  • Phone: 347-873-2680
  • Fax:
Mailing address:
  • Phone: 347-873-2680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP273088
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2300613
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 9410212
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number685726-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: