Provider Demographics
NPI:1588004766
Name:GREEN, CARLA L (APN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-1353
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18086363LF0000X
VA0024171230363LF0000X
TNRN0000162033163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I503370Medicare PIN
TN103I502797Medicare PIN
VAVVI298B288Medicare PIN