Provider Demographics
NPI:1235545849
Name:PETGRAVE, YONIQUE PETRECE (MD)
Entity Type:Individual
Prefix:DR
First Name:YONIQUE
Middle Name:PETRECE
Last Name:PETGRAVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 POPLAR AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4607
Mailing Address - Country:US
Mailing Address - Phone:901-287-8693
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST STE 400
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4625
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19723390200000X
TN604072080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program