Provider Demographics
NPI:1740728823
Name:PETTIS, JULIE (FNP)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:PETTIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3489 NEW BUCKEYE RD
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-3770
Mailing Address - Country:US
Mailing Address - Phone:478-609-4269
Mailing Address - Fax:
Practice Address - Street 1:200 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2981
Practice Address - Country:US
Practice Address - Phone:478-274-3865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN190687363LS0200X
GAF04170449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool