Provider Demographics
NPI:1437192978
Name:GREEN, SUSAN HELEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:HELEN
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E BETHANY HOME RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012
Mailing Address - Country:US
Mailing Address - Phone:480-275-2022
Mailing Address - Fax:888-551-6092
Practice Address - Street 1:520 E BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1207
Practice Address - Country:US
Practice Address - Phone:480-275-2022
Practice Address - Fax:888-551-6092
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN105876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ088645Medicaid
AZZ144416Medicare PIN