Healthcare Provider Details

I. General information

NPI: 1427869528
Provider Name (Legal Business Name): NIA IMANI DENNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIA IMANI GREEN FNP

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5706 GROVE AVE
RICHMOND VA
23226-2343
US

IV. Provider business mailing address

6540 CARTERS WALK LN
NORTH CHESTERFIELD VA
23234-6345
US

V. Phone/Fax

Practice location:
  • Phone: 804-325-4795
  • Fax:
Mailing address:
  • Phone: 804-429-9102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24192332
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: