Provider Demographics
NPI:1114110558
Name:GREEN, DEBRA (MSN, C-FNP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSN, C-FNP
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 95590
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-5590
Mailing Address - Country:US
Mailing Address - Phone:505-503-6800
Mailing Address - Fax:866-530-1835
Practice Address - Street 1:1524 EUBANK BLVD NE STE 6
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4160
Practice Address - Country:US
Practice Address - Phone:505-503-8600
Practice Address - Fax:888-503-8511
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00871208100000X
NMR39646363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1114110558Medicaid
NM58606823Medicaid