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General NPI Number Information
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NPI Number | 1033779657
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Entity Type | Individual
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Provider Name | JODI LYNNE PETTYGROVE FNP
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Gender | Female
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Dates
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Enumeration Date | 06/17/2019
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Last Update Date | 06/17/2019
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Provider Practice Location Address
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Address Line | 115 HAVELOCK CIR
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City | WARNER ROBINS
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State | GA
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Zip | 31088
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Country | US
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Telephone | 478-334-7958
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 464
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City | WALWORTH
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State | WI
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Zip | 53184-0464
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Country | US
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Telephone | 918-800-9066
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN263633
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License Number State | GA
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