=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083196836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETA-GAYE C PILOTE RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2018
-----------------------------------------------------
Last Update Date | 08/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 REGAL WAY E
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-559-2488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 319 REGAL WAY E
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-8248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-559-2488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | PCH007436
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Registered Nurse
-----------------------------------------------------
License Number | RN249535
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------