MEDICARE: MS. SHNITA GREGORY WILEY FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN271352	GA

General Provider Information

NPI Number	:	1053914341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHNITA GREGORY WILEY FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 386
Second Line	:
City	:	GROVETOWN
State	:	GA
Zip	:	30813-0386
Country	:	US
Telephone Number	:	706-399-9624
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 PORTER LN
Second Line	:
City	:	GROVETOWN
State	:	GA
Zip	:	30813-2271
Country	:	US
Telephone Number	:	706-399-9624
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	08/29/2021

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