Provider Demographics
NPI:1629719950
Name:PETCKA, NICOLE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:PETCKA
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 1:1280 LEAR LN APT 14
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7262
Mailing Address - Country:US
Mailing Address - Phone:920-883-8740
Mailing Address - Fax:
Practice Address - Street 1:H100 EMORY UNIVERSITY HOSPITAL 1364 CLIFTON ROAD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-0001
Practice Address - Country:US
Practice Address - Phone:009-340-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program