Provider Demographics
NPI:1639520174
Name:GREEN, AMIE L (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 TOWNPARK DR NW
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3715
Mailing Address - Country:US
Mailing Address - Phone:770-485-3723
Mailing Address - Fax:
Practice Address - Street 1:14 RIVERBEND DR SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6066
Practice Address - Country:US
Practice Address - Phone:706-234-0094
Practice Address - Fax:877-761-3771
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner