Provider Demographics
NPI:1437481074
Name:GREEN, STACY JO (CRNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WASHINGTON TOWNE BLVD N
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-1254
Mailing Address - Country:US
Mailing Address - Phone:814-877-7500
Mailing Address - Fax:814-877-7510
Practice Address - Street 1:120 WASHINGTON TOWNE BLVD N
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-1254
Practice Address - Country:US
Practice Address - Phone:814-877-7500
Practice Address - Fax:814-877-7510
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010692363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner