Provider Demographics
NPI:1740225820
Name:GREEN, LORI SHEA JEAN (NP)
Entity Type:Individual
Prefix:
First Name:LORI SHEA
Middle Name:JEAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7906
Mailing Address - Fax:615-920-8938
Practice Address - Street 1:313 FEDERAL DR NW STE 130
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-3099
Practice Address - Country:US
Practice Address - Phone:812-734-3952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005070207Q00000X
IN71000547A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100151870Medicaid
IN1017630001OtherDMERC
IN271288OtherANTHEM
IN331310HMedicare ID - Type Unspecified
KYP400034872Medicare PIN