Provider Demographics
NPI:1003105610
Name:GREEN, MERRY LYN (ANP)
Entity Type:Individual
Prefix:MRS
First Name:MERRY LYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S MAIN ST STE 1300
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5513
Mailing Address - Country:US
Mailing Address - Phone:669-490-1088
Mailing Address - Fax:
Practice Address - Street 1:845 3RD AVE FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-6630
Practice Address - Country:US
Practice Address - Phone:866-949-0108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305656-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03552090Medicaid
NYJ400084968Medicare PIN