Provider Demographics
NPI:1558816462
Name:GREEN, RACHAEL (AGNP-C)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80883
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0883
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:706-549-0151
Practice Address - Street 1:251 N LYERLY ST
Practice Address - Street 2:STE 100
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2743
Practice Address - Country:US
Practice Address - Phone:706-549-8114
Practice Address - Fax:706-549-0151
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2023-04-06
Deactivation Date:2023-03-29
Deactivation Code:
Reactivation Date:2023-04-06
Provider Licenses
StateLicense IDTaxonomies
CT154994363LA2200X
GA159821363LA2200X
TN21577363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health