Provider Demographics
NPI:1114062882
Name:PETCHENIK, NICOLE B (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:B
Last Name:PETCHENIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:YONA
Other - Last Name:BAUMGARTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4360 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:SUITE 370
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1049
Mailing Address - Country:US
Mailing Address - Phone:770-399-5055
Mailing Address - Fax:770-399-9638
Practice Address - Street 1:4360 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:SUITE 370
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1049
Practice Address - Country:US
Practice Address - Phone:770-399-5055
Practice Address - Fax:770-399-9638
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063116207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA589407380CMedicaid
GA589407380FMedicaid
GA589407380BMedicaid