Basic Information
| Provider Information | |||||||||
| NPI: | 1376588095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTWAY | ||||||||
| FirstName: | LAQUETTA | ||||||||
| MiddleName: | NICOL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746063 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 MONTGOMERY HWY | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | VESTAVIA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352162749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059787550 | ||||||||
| FaxNumber: | 2059787551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.19390 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051119644 | 01 | AL | BCBS | OTHER | 1376588095 | 01 | AL | TRICARE SOUTH | OTHER |