Provider Demographics
NPI:1760774772
Name:GREEN, LISA RENEE (DNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2723
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27802-2723
Mailing Address - Country:US
Mailing Address - Phone:252-212-3486
Mailing Address - Fax:252-212-3497
Practice Address - Street 1:90 GUARDIAN CT
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3017
Practice Address - Country:US
Practice Address - Phone:252-212-3350
Practice Address - Fax:252-212-0322
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2018-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZRN098822163WP0200X
NC281796363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics