Provider Demographics
NPI:1376504357
Name:GREEN, STEPHANIE L (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:PEARCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 POLE CREEK XING STE 1
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-2902
Mailing Address - Country:US
Mailing Address - Phone:308-254-5544
Mailing Address - Fax:308-254-2672
Practice Address - Street 1:1000 POLE CREEK XING STE 1
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162
Practice Address - Country:US
Practice Address - Phone:308-254-5544
Practice Address - Fax:308-254-2672
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS804976363L00000X
COAPN.0992934-NP363LF0000X
NE2066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07358266Medicaid