Provider Demographics
NPI:1376764340
Name:PETTY, BRANDY ANNE (MS, ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:BRANDY
Middle Name:ANNE
Last Name:PETTY
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N KEVIN CT
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-2743
Mailing Address - Country:US
Mailing Address - Phone:912-486-7581
Mailing Address - Fax:912-486-7690
Practice Address - Street 1:GEORGIA SOUTHERN UNIVERSITY HANNER FIELDHOUSE
Practice Address - Street 2:HERTY DRIVE
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30460-0001
Practice Address - Country:US
Practice Address - Phone:912-486-7581
Practice Address - Fax:912-486-7690
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0010142081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine