Provider Demographics
NPI:1376588095
Name:PETTWAY, LAQUETTA NICOL (MD)
Entity Type:Individual
Prefix:DR
First Name:LAQUETTA
Middle Name:NICOL
Last Name:PETTWAY
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:PO BOX 746063
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6063
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:1360 MONTGOMERY HWY
Practice Address - Street 2:SUITE 114
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35216-2749
Practice Address - Country:US
Practice Address - Phone:205-978-7550
Practice Address - Fax:205-978-7551
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.19390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051119644OtherBCBS
AL1376588095OtherTRICARE SOUTH
AL102I934601Medicare PIN
ALG43425Medicare UPIN