Provider Demographics
NPI:1659553774
Name:GUNN, PETULA YENTER (NP)
Entity Type:Individual
Prefix:
First Name:PETULA
Middle Name:YENTER
Last Name:GUNN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PETULA
Other - Middle Name:ELSIE
Other - Last Name:YENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4544 LAKEFAIRE CT
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6963
Mailing Address - Country:US
Mailing Address - Phone:334-740-7495
Mailing Address - Fax:
Practice Address - Street 1:3180 N POINT PKWY STE 303
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4522
Practice Address - Country:US
Practice Address - Phone:678-205-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-090105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL166154Medicaid