Provider Demographics
NPI:1497341796
Name:PETIT-JONES, STACY (RN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PETIT-JONES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11355 MICHELLE WAY
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6263
Mailing Address - Country:US
Mailing Address - Phone:678-615-4029
Mailing Address - Fax:
Practice Address - Street 1:11355 MICHELLE WAY
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6263
Practice Address - Country:US
Practice Address - Phone:678-615-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN288323163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse