Provider Demographics
NPI:1902220429
Name:PETITO, ANDI CHRISTINE
Entity Type:Individual
Prefix:
First Name:ANDI
Middle Name:CHRISTINE
Last Name:PETITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDI
Other - Middle Name:CHRISTINE
Other - Last Name:DESTEFANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP
Mailing Address - Street 1:115 NEW ST STE B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-5328
Mailing Address - Country:US
Mailing Address - Phone:407-902-5399
Mailing Address - Fax:
Practice Address - Street 1:3110 CLIFTON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-4600
Practice Address - Country:US
Practice Address - Phone:407-902-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN225020363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health