Provider Demographics
NPI:1285193441
Name:GREEN, CARRIE ANNE (APN)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANNE
Other - Last Name:CROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:1000 W HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1007
Mailing Address - Country:US
Mailing Address - Phone:309-734-1414
Mailing Address - Fax:309-734-0323
Practice Address - Street 1:1000 W HARLEM AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1007
Practice Address - Country:US
Practice Address - Phone:309-734-1414
Practice Address - Fax:309-734-0323
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner