Provider Demographics
NPI:1851745939
Name:PETTY, TAKANA
Entity Type:Individual
Prefix:
First Name:TAKANA
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 BARBERRY LN
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-6913
Mailing Address - Country:US
Mailing Address - Phone:678-472-0394
Mailing Address - Fax:
Practice Address - Street 1:1227 BARBERRY LN
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-6913
Practice Address - Country:US
Practice Address - Phone:678-472-0394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker