Provider Demographics
NPI:1023017050
Name:GREEN, TINA MARIE (CRNP)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 APPLE LN
Mailing Address - Street 2:BOX 31
Mailing Address - City:NORTH BEND
Mailing Address - State:PA
Mailing Address - Zip Code:17760-9423
Mailing Address - Country:US
Mailing Address - Phone:570-923-2556
Mailing Address - Fax:
Practice Address - Street 1:402 E SYCAMORE RD
Practice Address - Street 2:BOX 398
Practice Address - City:SNOW SHOE
Practice Address - State:PA
Practice Address - Zip Code:16874-8832
Practice Address - Country:US
Practice Address - Phone:814-387-6857
Practice Address - Fax:814-387-6870
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN520073L163W00000X
PAVP006945B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
F1104016OtherNATIONAL AANP-CERT
PA017968OtherRX AUTH
PA101182180Medicaid
F1104016OtherNATIONAL AANP-CERT
PA017968OtherRX AUTH