Provider Demographics
NPI:1558992974
Name:GREEN, FAQUETA KENISHA (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:FAQUETA
Middle Name:KENISHA
Last Name:GREEN
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ROSEBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-5613
Mailing Address - Country:US
Mailing Address - Phone:912-224-3641
Mailing Address - Fax:
Practice Address - Street 1:633 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5970
Practice Address - Country:US
Practice Address - Phone:912-224-3641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA209710363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health