Provider Demographics
NPI:1083114730
Name:GREEN, GINA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7364
Mailing Address - Fax:502-568-7136
Practice Address - Street 1:2529 SIX MILE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2934
Practice Address - Country:US
Practice Address - Phone:502-491-5560
Practice Address - Fax:502-491-0214
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014463A363L00000X
KY3011037363LF0000X, 363L00000X
OH0032484363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3011037OtherKY NP LICENSE