Provider Demographics
NPI:1053062760
Name:PROVEAUX, PATRICIA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:PROVEAUX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PERIMETER CENTER PL NE APT 415
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-4217
Mailing Address - Country:US
Mailing Address - Phone:912-675-5735
Mailing Address - Fax:
Practice Address - Street 1:5461 MERIDIAN MARK RD STE 130
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3009
Practice Address - Country:US
Practice Address - Phone:404-255-2033
Practice Address - Fax:404-252-1901
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN254746163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse