Provider Demographics
NPI:1134291743
Name:GREEN, PAMELA DIANE (APRN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:DIANE
Other - Last Name:CHERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:5TH FLOOR MERCY PHO/CVO
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DR STE 201
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7907
Practice Address - Country:US
Practice Address - Phone:270-444-4250
Practice Address - Fax:270-444-4260
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004702363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN0807OtherR.R.M.C.
KY78015773Medicaid
KYK232280OtherMEDICARE PTAN
Q55304Medicare UPIN