Healthcare Provider Details

I. General information

NPI: 1477486702
Provider Name (Legal Business Name): GABRIELLE ANYA PETTEWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 NC HIGHWAY 42 W
WILSON NC
27893-7774
US

IV. Provider business mailing address

127 MEADOWMIST DR
GARNER NC
27529-6566
US

V. Phone/Fax

Practice location:
  • Phone: 252-265-4020
  • Fax: 252-237-4233
Mailing address:
  • Phone: 919-986-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30005187
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: