Provider Demographics
NPI:1407472780
Name:GREEN, ALLISON (NP)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
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 1:8454 CARRIAGE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-9805
Mailing Address - Country:US
Mailing Address - Phone:517-449-7106
Mailing Address - Fax:
Practice Address - Street 1:406 KENT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1707
Practice Address - Country:US
Practice Address - Phone:517-647-4166
Practice Address - Fax:517-647-2473
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner