Provider Demographics
NPI:1609340058
Name:GREEN-FARRIS, ALICIA MICHELLE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MICHELLE
Last Name:GREEN-FARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:MICHELLE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2313 CRESTWOOD
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-3603
Mailing Address - Country:US
Mailing Address - Phone:870-489-7220
Mailing Address - Fax:
Practice Address - Street 1:5510 S OLIVE ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7607
Practice Address - Country:US
Practice Address - Phone:888-852-1988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily