Provider Demographics
NPI:1750043204
Name:GREEN, ERIKA MICHELLE
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:MICHELLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11312 S BERG HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4023
Mailing Address - Country:US
Mailing Address - Phone:801-803-3821
Mailing Address - Fax:
Practice Address - Street 1:11312 S BERG HOLLOW LN
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4023
Practice Address - Country:US
Practice Address - Phone:801-803-3821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10611444-3102163W00000X
UT10611444-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse