Healthcare Provider Details

I. General information

NPI: 1588548929
Provider Name (Legal Business Name): MORGAN GENTRY VINES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 JOHN MADDOX DR NW STE 221
ROME GA
30165-1452
US

IV. Provider business mailing address

109 JOHN MADDOX DR NW STE 221
ROME GA
30165-1452
US

V. Phone/Fax

Practice location:
  • Phone: 706-420-3309
  • Fax: 706-203-3201
Mailing address:
  • Phone: 706-420-3309
  • Fax: 706-203-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN288483
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP288482
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: