Provider Demographics
NPI:1205000718
Name:GREEN, HOLLY JANE (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3601
Mailing Address - Country:US
Mailing Address - Phone:757-961-3055
Mailing Address - Fax:
Practice Address - Street 1:6401 AUBURN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3601
Practice Address - Country:US
Practice Address - Phone:757-961-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3464314405363LF0000X, 363L00000X
VA0024172990363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000064066Medicare PIN
VAVVJ3179834Medicare PIN
UT000068583Medicare PIN