MEDICARE: SRIDEVI VENUGOPAL

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	363L00000X	Nurse Practitioner	RN235224	GA
2	363LA2100X	Acute Care Nurse Practitioner	RN235224	GA

General Provider Information

NPI Number	:	1457129611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SRIDEVI VENUGOPAL

Provider Business Mailing Address
First Line	:	3392 CLUBLAND DR
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30068-2507
Country	:	US
Telephone Number	:	404-801-5353
Fax Number	:

Provider Business Practice Location Address
First Line	:	1255 HIGHWAY 54 W
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4526
Country	:	US
Telephone Number	:	770-716-0051
Fax Number	:

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

Provider Enumeration Date	:	12/18/2023
Last Update Date	:	01/14/2026

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Directions to “ SRIDEVI VENUGOPAL ” Practice Location

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