Provider Demographics
NPI:1467971416
Name:GREENE, ANGELA M (PMHNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:GREENE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SPEERS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-7549
Mailing Address - Country:US
Mailing Address - Phone:601-906-7091
Mailing Address - Fax:
Practice Address - Street 1:3531 LAKELAND DR STE 1060
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8016
Practice Address - Country:US
Practice Address - Phone:601-420-5810
Practice Address - Fax:601-420-5811
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866891163W00000X, 363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner