Provider Demographics
NPI:1598390791
Name:GREEN, COLLEEN M (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 W BLUE STAR DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757-8496
Mailing Address - Country:US
Mailing Address - Phone:520-260-6763
Mailing Address - Fax:
Practice Address - Street 1:1260 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-0504
Practice Address - Country:US
Practice Address - Phone:520-407-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-08
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ239266363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health