Provider Demographics
NPI:1619959889
Name:GREEN, AMY A (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:AYCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2151 OLD ROCKY RIDGE
Mailing Address - Street 2:#106
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216
Mailing Address - Country:US
Mailing Address - Phone:205-989-1080
Mailing Address - Fax:
Practice Address - Street 1:2010 BROOKWOOD MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35216
Practice Address - Country:US
Practice Address - Phone:205-989-1080
Practice Address - Fax:205-989-1087
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1082067367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51113132Medicaid
AL430079110OtherRR MEDICARE
AL51553132Medicare ID - Type Unspecified
AL430079110OtherRR MEDICARE