Healthcare Provider Details

I. General information

NPI: 1235545849
Provider Name (Legal Business Name): YONIQUE PETRECE PETGRAVE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST STE 400
MEMPHIS TN
38105-4625
US

IV. Provider business mailing address

850 POPLAR AVE BLDG 2
MEMPHIS TN
38105-4607
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-7337
  • Fax:
Mailing address:
  • Phone: 901-287-8693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number19723
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number60407
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: