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General NPI Number Information
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NPI Number | 1558124628
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Entity Type | Individual
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Provider Name | GEREMY LANCE WOOTEN MSN, APRN, PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 02/01/2024
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Last Update Date | 03/20/2024
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Provider Practice Location Address
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Address Line | 2540 WINDY HILL RD SE
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City | MARIETTA
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State | GA
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Zip | 30067-8605
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Country | US
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Telephone | 770-644-1570
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Fax | 770-644-1576
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Provider Business Mailing Address
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Address Line | 128 VIVIAN LN
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-2305
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Country | US
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Telephone | 646-467-1015
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | RN205927
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License Number State | GA
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