Provider Demographics
NPI:1710457247
Name:GREEN, MARY ANN (PMHNP-BC, APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:WADLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30477-0306
Mailing Address - Country:US
Mailing Address - Phone:706-831-2715
Mailing Address - Fax:
Practice Address - Street 1:223 N ANDERSON DR
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-4440
Practice Address - Country:US
Practice Address - Phone:478-289-2522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113823363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health