Provider Demographics
NPI:1558124628
Name:WOOTEN, GEREMY LANCE (MSN, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:GEREMY
Middle Name:LANCE
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 VIVIAN LN
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2305
Mailing Address - Country:US
Mailing Address - Phone:646-467-1015
Mailing Address - Fax:
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:770-644-1570
Practice Address - Fax:770-644-1576
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205927363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health