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General NPI Number Information
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NPI Number | 1043541725
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Entity Type | Individual
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Provider Name | JANINE NICOLE PETTIFORD M.D.
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Gender | Female
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Dates
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Enumeration Date | 01/20/2010
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Last Update Date | 11/08/2016
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Provider Practice Location Address
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Address Line | 325 NORTH JEFF DAVIS DR
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City | FAYETTEVILLE
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State | GA
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Zip | 30214
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Country | US
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Telephone | 770-461-1337
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Fax | 770-461-0922
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Provider Business Mailing Address
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Address Line | 33 UPPER RIVERDALE ROAD SW SUITE 112
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1627
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Country | US
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Telephone | 770-996-3190
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | BP10023659
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 2010013505
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 072414
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License Number State | GA
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