Provider Demographics
NPI:1073620530
Name:GREEN, DONNIELLE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:DONNIELLE
Middle Name:LYNN
Last Name:GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470408
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-0408
Mailing Address - Country:US
Mailing Address - Phone:980-295-8574
Mailing Address - Fax:
Practice Address - Street 1:951 WENDOVER HEIGHT DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3565
Practice Address - Country:US
Practice Address - Phone:704-487-4677
Practice Address - Fax:704-887-6450
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC894207R00000X
NC2012-01587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC008949Medicaid
AA12068171Medicare ID - Type Unspecified
SC008949Medicaid