Provider Demographics
NPI:1316580657
Name:GREEN, CASSANDRA (FNP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 300
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8622
Practice Address - Country:US
Practice Address - Phone:765-485-8649
Practice Address - Fax:765-485-8650
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009464A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300032257Medicaid