Provider Demographics
NPI:1053880849
Name:VESSEL, MARY (PMHNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VESSEL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 ORMEWOOD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3618
Mailing Address - Country:US
Mailing Address - Phone:404-759-5262
Mailing Address - Fax:
Practice Address - Street 1:2900 CHAMBLEE TUCKER RD BLDG 16
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4148
Practice Address - Country:US
Practice Address - Phone:770-939-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165645363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003214635AMedicaid