Provider Demographics
NPI:1609234129
Name:GREEN, TAMMY (CPNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 SUMMERLAKE WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7424
Mailing Address - Country:US
Mailing Address - Phone:404-669-7949
Mailing Address - Fax:678-583-5484
Practice Address - Street 1:5040 BILL GARDNER PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3757
Practice Address - Country:US
Practice Address - Phone:678-583-5437
Practice Address - Fax:678-583-5484
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN199156363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics