Provider Demographics
NPI:1619591120
Name:PROENZA, ELISABETH ANN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:ANN
Last Name:PROENZA
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 1:210 MOSE COLEMAN DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8677
Mailing Address - Country:US
Mailing Address - Phone:912-537-2200
Mailing Address - Fax:912-537-2260
Practice Address - Street 1:210 MOSE COLEMAN DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8677
Practice Address - Country:US
Practice Address - Phone:912-308-6484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-31
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN156767363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN156767OtherADVANCED PRACTICE -NP NUMBER