Healthcare Provider Details

I. General information

NPI: 1982106373
Provider Name (Legal Business Name): VICTORIA CARRIESA GREEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MILSTEAD RD NE STE 110
CONYERS GA
30012-3849
US

IV. Provider business mailing address

1835 SAVOY DR STE 203
ATLANTA GA
30341-1073
US

V. Phone/Fax

Practice location:
  • Phone: 770-496-9430
  • Fax: 404-891-4947
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN207510
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: