Healthcare Provider Details

I. General information

NPI: 1275005449
Provider Name (Legal Business Name): VIVIENE VERONA GRAY FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIVIENE VERONA SMITH PMHNP

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 CORPORATE CENTRE BLVD STE 240
ORLANDO FL
32822-3217
US

IV. Provider business mailing address

7101 SECRET ROSE
DOUGLASVILLE GA
30134-1669
US

V. Phone/Fax

Practice location:
  • Phone: 407-641-0478
  • Fax:
Mailing address:
  • Phone: 678-914-2806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberAPRN11020332
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number176138
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: