Healthcare Provider Details

I. General information

NPI: 1740928803
Provider Name (Legal Business Name): WESLEY ALLEN PETTIFORD FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S CHARLES G SEIVERS BLVD
CLINTON TN
37716-3916
US

IV. Provider business mailing address

114 ARCADIAN SPRINGS DR
ANDERSONVILLE TN
37705-3032
US

V. Phone/Fax

Practice location:
  • Phone: 865-457-4702
  • Fax:
Mailing address:
  • Phone: 865-250-4219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31793
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: