Healthcare Provider Details

I. General information

NPI: 1992508899
Provider Name (Legal Business Name): INGRID VIERA FLEETWOOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 PARKER RD SE STE B240
CONYERS GA
30094-6673
US

IV. Provider business mailing address

1765 PARKER RD SE
CONYERS GA
30094-6652
US

V. Phone/Fax

Practice location:
  • Phone: 770-602-2970
  • Fax:
Mailing address:
  • Phone: 770-602-2970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN250470
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN250470
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: