Provider Demographics
NPI:1073991931
Name:GREEN, MICHELLE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 SOUTHWEST LANKTREE GLENN
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038
Mailing Address - Country:US
Mailing Address - Phone:386-623-3964
Mailing Address - Fax:
Practice Address - Street 1:4343 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2817
Practice Address - Country:US
Practice Address - Phone:386-623-3964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3172562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily