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General NPI Number Information
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NPI Number | 1629719950
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Entity Type | Individual
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Provider Name | NICOLE LYNN PETCKA MD
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Gender | Female
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Dates
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Enumeration Date | 04/01/2022
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Last Update Date | 04/01/2022
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Provider Practice Location Address
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Address Line | H100 EMORY UNIVERSITY HOSPITAL 1364 CLIFTON ROAD NE
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City | ATLANTA
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State | GA
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Zip | 30322-0001
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Country | US
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Telephone | 9-340-4727
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Fax |
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Provider Business Mailing Address
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Address Line | 1280 LEAR LN APT 14
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City | DE PERE
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State | WI
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Zip | 54115-7262
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Country | US
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Telephone | 920-883-8740
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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