Provider Demographics
NPI:1922768381
Name:PETITHOMME, MERLANDE LEONNA (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:MS
First Name:MERLANDE
Middle Name:LEONNA
Last Name:PETITHOMME
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:MS
Other - First Name:MERLANDE
Other - Middle Name:LEONNA
Other - Last Name:PETITHOMME
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRANIAL PROTHESIS SP
Mailing Address - Street 1:5975 ROSWELL RD
Mailing Address - Street 2:C-343, FLAT-8
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-771-1981
Mailing Address - Fax:
Practice Address - Street 1:5975 ROSWELL RD
Practice Address - Street 2:C-343, FLAT-8
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:770-771-1981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACO129741OtherMEDICAL INSURANCE