=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053914341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHNITA GREGORY WILEY FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 08/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 PORTER LN
-----------------------------------------------------
City | GROVETOWN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30813-2271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-399-9624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 386
-----------------------------------------------------
City | GROVETOWN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30813-0386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-399-9624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN271352
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------