Provider Demographics
NPI:1275005449
Name:GRAY, VIVIENE VERONA (FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:VIVIENE
Middle Name:VERONA
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:VIVIENE
Other - Middle Name:VERONA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
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 1:6545 CORPORATE CENTRE BLVD STE 240
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-3217
Practice Address - Country:US
Practice Address - Phone:407-641-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020332163WG0000X
GA176138363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice