Provider Demographics
NPI:1275005449
Name:SMITH, VIVIENE VERONA (FNP-C)
Entity Type:Individual
Prefix:
First Name:VIVIENE
Middle Name:VERONA
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 SECRET ROSE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1669
Mailing Address - Country:US
Mailing Address - Phone:678-914-2806
Mailing Address - Fax:
Practice Address - Street 1:5130 SUNFOREST DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-6318
Practice Address - Country:US
Practice Address - Phone:657-400-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA176138363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health