Provider Demographics
NPI:1376322172
Name:PETTAWAY, TERI KAYE (NP)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:KAYE
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:KAYE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:129 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4949
Mailing Address - Country:US
Mailing Address - Phone:803-774-9000
Mailing Address - Fax:
Practice Address - Street 1:129 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4949
Practice Address - Country:US
Practice Address - Phone:803-774-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28655363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care