Provider Demographics
NPI:1558331439
Name:GREEN, PHYLLIS R (WHCNP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:MRS
Other - First Name:PHYLLIS
Other - Middle Name:R
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3425 1ST AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-6155
Mailing Address - Country:US
Mailing Address - Phone:319-363-3459
Mailing Address - Fax:
Practice Address - Street 1:3425 1ST AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-6155
Practice Address - Country:US
Practice Address - Phone:319-363-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF-076357363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
07-12543OtherMEDICA
1043738OtherAMERICA'S PPO (ARAZ)
MN095817400Medicaid
SD6826080Medicaid
SD6826082Medicaid
HP39675OtherHEALTH PARTNERS
23511OtherSIOUX VALLEY HEALTH PLAN
122187OtherUCARE
MN32B01BEOtherBCBS MN
SD4998913OtherBCBS SD (WELLMARK)
NE10025013500Medicaid
1017855OtherPREFERRED ONE
SD4998568OtherBCBS SD (WELLMARK)
1017855OtherPREFERRED ONE
1043738OtherAMERICA'S PPO (ARAZ)