Provider Demographics
NPI:1790906840
Name:GREEN, SUSAN ROBIN (MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROBIN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 HENRY AVE
Mailing Address - Street 2:C15
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128
Mailing Address - Country:US
Mailing Address - Phone:215-487-1017
Mailing Address - Fax:
Practice Address - Street 1:131 E CHELTEN AVE
Practice Address - Street 2:PHILADELPHIA PUBLIC HEALTH DEPT HEALTH CARE CENTER #9
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144
Practice Address - Country:US
Practice Address - Phone:215-685-5701
Practice Address - Fax:215-685-5257
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN266978L363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN266978LOtherREGISTERED NURSE
VP004121GOtherOBSTETRIC GYNECOLOGY