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General NPI Number Information
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NPI Number | 1902249675
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Entity Type | Individual
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Provider Name | MONIQUE DIANE PETTEYS FNP-C
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Gender | Female
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Dates
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Enumeration Date | 04/12/2013
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Last Update Date | 10/20/2025
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Provider Practice Location Address
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Address Line | 189 BO JAMES ST STE 105
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City | CLAYTON
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State | GA
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Zip | 30525-6199
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Country | US
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Telephone | 706-782-0016
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Fax | 706-782-0180
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Provider Business Mailing Address
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Address Line | 647 ACADEMY RD
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City | LONG CREEK
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State | SC
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Zip | 29658-2105
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Country | US
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Telephone | 706-982-4434
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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 | RN184994
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License Number State | GA
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