Provider Demographics
NPI:1912211764
Name:PETTIGREW, MADISON D (MSN, APN, PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:MADISON
Middle Name:D
Last Name:PETTIGREW
Suffix:
Gender:M
Credentials:MSN, APN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8130 COUNTRY VILLAGE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2087
Mailing Address - Country:US
Mailing Address - Phone:901-308-2915
Mailing Address - Fax:901-308-2924
Practice Address - Street 1:8130 COUNTRY VILLAGE DR STE 103
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2087
Practice Address - Country:US
Practice Address - Phone:901-308-2915
Practice Address - Fax:901-308-2924
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171949163W00000X
MS904213363LP0808X
TN28484363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT24221AMedicaid
MS1I5219OtherMEDICARE